Prognosis and improved outcomes in major depression: a review

Identifying depression disorder using multi-view high-order brain function network derived from electroencephalography signal

Brain function networks (BFN) are widely used in the diagnosis of electroencephalography (EEG)-based major depressive disorder (MDD). Typically, a BFN is constructed by calculating the functional connectivity (FC) between each pair of channels. However, it ignores high-order relationships (e.g., relationships among multiple channels), making it a low-order network. To address this issue, a novel classification framework, based on matrix variate normal distribution (MVND), is proposed in this study. The framework can simultaneously generate high-and low-order BFN and has a distinct mathematical interpretation. Specifically, the entire time series is first divided into multiple epochs. For each epoch, a BFN is constructed by calculating the phase lag index (PLI) between different EEG channels. The BFNs are then used as samples, maximizing the likelihood of MVND to simultaneously estimate its low-order BFN (Lo-BFN) and high-order BFN (Ho-BFN). In addition, to solve the problem of the excessively high dimensionality of Ho-BFN, Kronecker product decomposition is used for dimensionality reduction while retaining the original high-order information. The experimental results verified the effectiveness of Ho-BFN for MDD diagnosis in 24 patients and 24 normal controls. We further investigated the selected discriminative Lo-BFN and Ho-BFN features and revealed that those extracted from different networks can provide complementary information, which is beneficial for MDD diagnosis.

Involvement of the IL-6 Signaling Pathway in the Anti-Anhedonic Effect of the Antidepressant Agomelatine in the Chronic Mild Stress Model of Depression

Neuroinflammation has emerged as an important factor in the molecular underpinnings of major depressive disorder (MDD) pathophysiology and in the mechanism of action of antidepressants. Among the inflammatory mediators dysregulated in depressed patients, interleukin (IL)-6 has recently been proposed to play a crucial role. IL-6 activates a signaling pathway comprising the JAK/STAT proteins and characterized by a specific negative feedback loop exerted by the cytoplasmic protein suppressor of cytokine signalling-3 (SOCS3). On these bases, here, we explored the potential involvement of IL-6 signaling in the ability of the antidepressant drug agomelatine to normalize the anhedonic-like phenotype induced in the rat by chronic stress exposure. To this aim, adult male Wistar rats were subjected to the chronic mild stress (CMS) paradigm and chronically treated with vehicle or agomelatine. The behavioral evaluation was assessed by the sucrose consumption test, whereas molecular analyses were performed in the prefrontal cortex. We found that CMS was able to stimulate IL-6 production and signaling, including SOCS3 gene and protein expression, but the SOCS3-mediated feedback-loop inhibition failed to suppress the IL-6 cascade in stressed animals. Conversely, agomelatine treatment normalized the stress-induced decrease in sucrose consumption and restored the negative modulation of the IL-6 signaling via SOCS3 expression and activity. Our results provide additional information about the pleiotropic mechanisms that contribute to agomelatine’s therapeutic effects.

Multicentre narrative research on major depression to integrate the experiences of patients, their caregivers and healthcare providers in Italy

OBJECTIVE

This research aimed to investigate the experience of major depression by integrating the perspectives of patients, caregivers and healthcare providers through narrative-based medicine (NBM) to provide new insights to improve care relationships.

DESIGN AND SETTING

The research was conducted in 2019 and involved five Italian psychiatric centres and targeted adult patients, their caregivers and healthcare providers to address data source triangulation. A sociodemographic survey and a narrative plot, based on Natural Semantic Metalanguage were collected. Narratives were analysed through NBM classifications, NVivo software and interpretative coding.

PARTICIPANTS

Thirty-six patients with a diagnosis of major depression, 27 caregivers and 33 healthcare providers participated in the research.

RESULTS

Among the 96 collected narratives, 'lonely' was the word patients used most frequently, while 'sad' and 'lifeless' were used most respectively by caregivers and healthcare providers. A positive care relationship was crucial for 84% of patients in relation to their care pathway, and nature (36%) and the arts (28%) were the most frequent resources. Caregivers expressed feelings of powerlessness and inadequacy, and 21% of them reported a declining social life while providing care to a loved one with depression. Thirty-one percent of mental health professionals experienced difficulties in their first encounter with patients; however, their emotions progressively moved towards trust and satisfaction. Furthermore, 89% of patients and healthcare providers and 58% of caregivers evaluated writing the narrative to be a positive experience.

CONCLUSION

Findings suggested the possible role for language in understanding major depression, thereby improving care relationships between patients and physicians. Care pathways might also be more attentive to caregivers, to reduce their risk of burnout. Finally, narrative medicine could be integrated with the care pathway as an additional space of expression, dialogue, reflection and development of empathy.

Stratification of individuals with lifetime depression and low wellbeing in the UK Biobank

BACKGROUND

Previous studies stratified patients with major depressive disorder (MDD) based on their clinical characteristics. This study used this approach in individuals with lifetime MDD who reported low wellbeing, a group of high clinical relevance.

METHODS

We selected participants in the UK Biobank (UKB) with lifetime MDD and a wellbeing score in the lowest 25 %. A wellbeing score was previously created considering happiness, belief that own life is meaningful, health satisfaction and functioning in relevant areas. In the selected group, we applied latent class analysis using mood-spectrum symptoms and personality traits as input variables, then we compared the clinical-demographic and genetic (polygenic risk scores, PRSs) characteristics of the identified classes.

RESULTS

A total of 13,896 individuals were included and a model with five classes showed the best performance. The most common class (31.25 %) was characterised by periods of irritable mood and trait irritability with high neuroticism. A rarer class (16.49 %) showed depressive-manic mood fluctuations and risk-taking personality, higher percentage of males, atypical depressive symptoms, lower socio-economic status, higher PRS for attention-deficit hyperactivity disorder and lower PRS for education. The second most common class (29.79 %) showed worry as main personality trait with low risk of manic/irritable manifestations. The remaining classes showed an anxious-irritable personality profile and a purely depressive profile (4.92 % and 17.55 %, respectively).

LIMITATIONS

Our results may reflect the characteristics of UKB participants.

CONCLUSIONS

Subthreshold manic/irritable mood fluctuations and personality traits irritability and neuroticism may distinguish the most common groups with poor wellbeing in lifetime MDD.

Retinal markers of therapeutic responses in major depressive disorder: Effects of antidepressants on retinal function

BACKGROUND

One goal of research into major depressive disorder (MDD) is to develop markers to predict and monitor the response to psychotropic treatments. The retina is endowed with a complex neurotransmission system, composed of the main neurotransmitters involved in the pathophysiology of MDD. The retina is therefore a relevant site of investigation for the identification of reliable and robust markers. However, the effects of antidepressants on the human retina are poorly studied. Here, we seek to study the potential specific effects of various antidepressants on retinal function in MDD patients.

METHODS

We assessed retinal function using flash (fERG), pattern (PERG) and multifocal (mfERG) electroretinogram in 19 MDD patients treated using antidepressants at baseline and at weeks 4, 8 and 12.

RESULTS

We observed reduced b-wave amplitude of photopic fERG 3.0 in patients treated with Selective Serotonin Reuptake Inhibitor (SSRI) in comparison with patients treated with Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) or Tricyclic Antidepressant (TCAD). We also showed that SNRIs were associated both with a decrease in PERG P50 implicit time and an increase in fERG 3.0 b-wave amplitude. TCADs were associated with an increase in fERG flicker 3.0 a- and b-wave amplitude.

CONCLUSIONS

This is the first study in real-life conditions to show a specific effect of various antidepressants on retinal function evaluated by electroretinogram. Further investigations should be led to specify the effects of antidepressants on ERG in order to isolate reliable and reproducible markers for predicting and monitoring the response to antidepressants.

Health care utilisation in treatment-resistant depression: a Swedish population-based cohort study

OBJECTIVE

To investigate the health care utilisation (HCU) among patients with treatment-resistant depression (TRD) compared to patients with depression not meeting TRD criteria.

METHODS

Nationwide Swedish registers were used to identify patients 18-69 years old with incident depression and antidepressant treatment. Patients were followed prospectively and defined as having TRD at start of the third distinct consecutive treatment episode. Each of the 16,329 identified TRD patients were matched with five comparators with depression not meeting criteria for TRD. Main outcome measure was total number of inpatient days and outpatient visits, and secondary outcome was HCU in connection with a main diagnosis of depression or suicide attempt.

RESULTS

TRD patients had a significantly higher risk of all-cause inpatient care than comparators (first year adjusted risk ratio [aRR] 3.03 [95%CI 3.01-3.05], years 1-3 aRR 2.15 [2.13-2.16]). This was more pronounced when the main diagnosis was depression (first year aRR 4.41 [4.36-4.45]), and after suicide attempt (first year aRR 4.43 [4.26-4.60]). Outpatient visits were also markedly more frequent for patients with TRD (first year aRR 2.05 [2.03-2.07]). Higher HCU among TRD patients persisted throughout follow-up.

CONCLUSIONS

Patients with TRD may have a twofold to fourfold higher HCU than other patients with depression.KEYPOINTSThis register-based prospective study investigated health care utilisation (HCU) among patients with treatment-resistant depression (TRD) compared to other patients with depression.Patients with TRD had a two to fourfold higher HCU regarding all measured outcomes, including inpatient hospital days and outpatient visits.The elevated HCU persisted for more than three years, although decreasing gradually. This should correspond to increased costs and individual burden for patients with TRD.

Concordance of the treatment patterns for major depressive disorders between the Canadian Network for Mood and Anxiety Treatments (CANMAT) algorithm and real-world practice in China

Background: Antidepressant (AD) algorithm is an important tool to support treatment decision-making and improve management of major depressive disorder (MDD). However, little is known about its concordance with real-world practice. This study aimed to assess the concordance between the longitudinal treatment patterns and AD algorithm recommended by a clinical practice guideline in China. Methods: Data were obtained from the electronic medical records of Shanghai Mental Health Center (SMHC), one of the largest mental health institutions in China. We examined the concordance between clinical practice and the Canadian Network for Mood and Anxiety Treatments (CANMAT) algorithm among a cohort composed of 19,955 MDD patients. The longitudinal characteristics of treatment regimen and duration were described to identify the specific inconsistencies. Demographics and health utilizations of the algorithm-concordant and -discordant subgroups with optimized treatment were measured separately. Results: The overall proportion of algorithm-concordant treatment significantly increased from 84.45% to 86.03% during the year of 2015-2017. Among the patients who received recommended first-line drugs with subsequent optimized treatment (n = 2977), the concordance proportion was 27.24%. Mirtazapine and trazodone were the most used drugs for adjunctive strategy. Inadequate or extended duration before optimized treatment are common inconsistency. The median length of follow-up for algorithm-concordant (n = 811) and algorithm-discordant patients (n = 2166) were 153 days (Q1-Q3 = 79-328) and 368 days (Q1-Q3 = 181-577) respectively, and the average number of clinical visits per person-year was 13.07 and 13.08 respectively. Conclusion: Gap existed between clinical practice and AD algorithm. Improved access to evidence-based treatment is required, especially for optimized strategies during outpatient follow-up.

Is subthreshold depression in adolescence clinically relevant?

BACKGROUND

Subthreshold depression is highly prevalent in adolescence, but compared to major depressive disorder, the clinical impact is under-researched. The aim of this review was to compare subthreshold depression and major depressive disorder in adolescents by reviewing available literature on epidemiology, risk factors, illness trajectories, brain anatomy and function, genetics, and treatment response.

METHODS

We conducted a scoping review of papers on subthreshold depression and major depressive disorder in adolescence published in English. Studies in adults were included when research in adolescence was not available.

RESULTS

We found that individuals with subthreshold depression were similar to individuals with major depressive disorder in several regards, including female/male ratio, onset, functional impairment, comorbidity, health care utilization, suicidal ideation, genetic predisposition, brain alterations, and treatment response. Further, subthreshold depression was about two times more common than major depressive disorder.

LIMITATIONS

The definition of subthreshold depression is highly variable across studies. Adolescent-specific data are limited in the areas of neurobiology and treatment.

CONCLUSIONS

The findings of the current review support the idea that subthreshold depression is of clinical importance and provide evidence for a spectrum, versus categorical model, for depressive symptomatology. Given the frequency of subthreshold depression escalating to major depressive disorder, a greater recognition and awareness of the significance of subthreshold depression in research, clinical practice and policy-making may facilitate the development and application of early prevention and intervention.

Multimodal Assessment of Schizophrenia and Depression Utilizing Video, Acoustic, Locomotor, Electroencephalographic, and Heart Rate Technology: Protocol for an Observational Study

Background

Current standards of psychiatric assessment and diagnostic evaluation rely primarily on the clinical subjective interpretation of a patient’s outward manifestations of their internal state. While psychometric tools can help to evaluate these behaviors more systematically, the tools still rely on the clinician’s interpretation of what are frequently nuanced speech and behavior patterns. With advances in computing power, increased availability of clinical data, and improving resolution of recording and sensor hardware (including acoustic, video, accelerometer, infrared, and other modalities), researchers have begun to demonstrate the feasibility of cutting-edge technologies in aiding the assessment of psychiatric disorders.

Objective

We present a research protocol that utilizes facial expression, eye gaze, voice and speech, locomotor, heart rate, and electroencephalography monitoring to assess schizophrenia symptoms and to distinguish patients with schizophrenia from those with other psychiatric disorders and control subjects.

Methods

We plan to recruit three outpatient groups: (1) 50 patients with schizophrenia, (2) 50 patients with unipolar major depressive disorder, and (3) 50 individuals with no psychiatric history. Using an internally developed semistructured interview, psychometrically validated clinical outcome measures, and a multimodal sensing system utilizing video, acoustic, actigraphic, heart rate, and electroencephalographic sensors, we aim to evaluate the system’s capacity in classifying subjects (schizophrenia, depression, or control), to evaluate the system’s sensitivity to within-group symptom severity, and to determine if such a system can further classify variations in disorder subtypes.

Results

Data collection began in July 2020 and is expected to continue through December 2022.

Conclusions

If successful, this study will help advance current progress in developing state-of-the-art technology to aid clinical psychiatric assessment and treatment. If our findings suggest that these technologies are capable of resolving diagnoses and symptoms to the level of current psychometric testing and clinician judgment, we would be among the first to develop a system that can eventually be used by clinicians to more objectively diagnose and assess schizophrenia and depression with the possibility of less risk of bias. Such a tool has the potential to improve accessibility to care; to aid clinicians in objectively evaluating diagnoses, severity of symptoms, and treatment efficacy through time; and to reduce treatment-related morbidity.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36417

Higher IL-6 and IL-4 plasma levels in depressed elderly women are influenced by diabetes mellitus

OBJECTIVE

This study aimed at investigating a set of peripheral cytokines in elderly female patients with MDD, comparing them to controls, and assessing the potential influence of clinical comorbidities on inflammatory markers.

METHODS

Twenty-five elderly female patients diagnosed with MDD and 19 age-matched female controls were enrolled on this study. Plasma levels of interleukin (IL)-4, IL-6, IL-10, interferon (IFN)-γ and tumor necrosis factor (TNF)-α were evaluated with commercially-available assays.

RESULTS

Elderly female patients with MDD exhibited higher plasma IL-6 and IL-4 levels when compared to controls. In a logistic regression model taking cytokine levels, comorbidities, and age into account, only type 2 diabetes mellitus (DM2) remained associated with MDD.

CONCLUSION

Diabetes influences the association between MDD and higher levels of cytokines in elderly female patients. Future studies should take this evidence into account in order to mitigate confounding factors.

Staging of unipolar depression: systematic review and discussion of clinical implications

Staging has been increasingly used in unipolar depression since its introduction in the nineties. Several models are available, but their differential features and implications are not completely clear. We systematically reviewed: (a) staging models of longitudinal development of unipolar depression; (b) staging models of treatment-resistant unipolar depression; (c) their applications. MEDLINE, PsycINFO, EMBASE, and Web of Science were examined according to PRISMA guidelines from inception to December 2021. Search terms were: 'stage/staging', combined using the Boolean 'AND' operator with 'psychiatric disorder/mental disorder/depressive/mood disorder'. A total of 169 studies were identified for inclusion: 18 described staging models or applications, 151 described treatment-resistant staging models or applications. Staging models of longitudinal development were found to play a key role in formulating sequential treatment, with particular reference to the use of psychotherapy after pharmacotherapy. Staging methods based on treatment resistance played a crucial role in setting entry criteria for randomized clinical trials and neurobiological investigations. Staging is part of clinimetrics, the science of clinical measurements, and its role can be enhanced by its association with other clinimetric strategies, such as repeated assessments, organization of problematic areas, and evaluation of phenomena that may affect responsiveness. In research, it may allow to identify more homogeneous populations in terms of treatment history that may diminish the likelihood of spurious results in comparisons. In clinical practice, the use of staging in a clinimetric perspective allows clinicians to make full use of the information that is available for an individual patient at a specific time.

Neurobiological, familial and genetic risk factors for dimensional psychopathology in the Adolescent Brain Cognitive Development study

BACKGROUND

Adolescence is a key period for brain development and the emergence of psychopathology. The Adolescent Brain Cognitive Development (ABCD) study was created to study the biopsychosocial factors underlying healthy and pathological brain development during this period, and comprises the world's largest youth cohort with neuroimaging, family history and genetic data.

METHODS

We examined 9856 unrelated 9-to-10-year-old participants in the ABCD study drawn from 21 sites across the United States, of which 7662 had multimodal magnetic resonance imaging scans passing quality control, and 4447 were non-Hispanic white and used for polygenic risk score analyses. Using data available at baseline, we associated eight 'syndrome scale scores' from the Child Behavior Checklist-summarizing anxious/depressed symptoms, withdrawn/depressed symptoms, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior-with resting-state functional and structural brain magnetic resonance imaging measures; eight indicators of family history of psychopathology; and polygenic risk scores for major depression, bipolar disorder, schizophrenia, attention deficit hyperactivity disorder (ADHD) and anorexia nervosa. As a sensitivity analysis, we excluded participants with clinically significant (>97th percentile) or borderline (93rd-97th percentile) scores for each dimension.

RESULTS

Most Child Behavior Checklist dimensions were associated with reduced functional connectivity within one or more of four large-scale brain networks-default mode, cingulo-parietal, dorsal attention, and retrosplenial-temporal. Several dimensions were also associated with increased functional connectivity between the default mode, dorsal attention, ventral attention and cingulo-opercular networks. Conversely, almost no global or regional brain structural measures were associated with any of the dimensions. Every family history indicator was associated with every dimension. Major depression polygenic risk was associated with six of the eight dimensions, whereas ADHD polygenic risk was exclusively associated with attention problems and externalizing behavior (rule-breaking and aggressive behavior). Bipolar disorder, schizophrenia and anorexia nervosa polygenic risk were not associated with any of the dimensions. Many associations remained statistically significant even after excluding participants with clinically significant or borderline psychopathology, suggesting that the same risk factors that contribute to clinically significant psychopathology also contribute to continuous variation within the clinically normal range.

CONCLUSIONS

This study codifies neurobiological, familial and genetic risk factors for dimensional psychopathology across a population-scale cohort of community-dwelling preadolescents. Future efforts are needed to understand how these multiple modalities of risk intersect to influence trajectories of psychopathology into late adolescence and adulthood.

Associations between Autoimmunity and Depression: Serum IL-6 and IL-17 Have Directly Impact on the HAMD Scores in Patients with First-Episode Depressive Disorder

Objective. The study is aimed at evaluating the immune-activation state before and after treatment in patients with first-episode depressive disorder (FDD) with evaluating the ILs and CRP levels and further clarifying the association between autoimmunity and the etiology and pathogenesis of FDD. Methods. We designed a case-control study. FDD patients and healthy subjects were enrolled in the FDD group and control group. Serum IL-6, IL-17, and CRP were measured before and after selective serotonin reuptake inhibitor (SSRI) therapy, as well as Hamilton rating scale for depression (HAMD) and life event scale (LES) scores. The correlations between IL-6 and IL-17 and HAMD and LES scores were analysed, and multiple linear regression analysis was performed for HAMD score. Results. 40 FDD patients and 40 healthy subjects were included in the FDD and control group from October 2009 to September 2012. Before treatment, the IL-6 ( $28.99\pm 5.51$ , $P<0.001$ ) and IL-17 ( $41.15\pm 4.80$ , $P<0.001$ ) in the FDD group were significantly higher than the control group ( $16.84\pm 3.78$ and $21.68\pm 3.72$ , respectively). The C-reactive protein (CRP) level in two groups was comparable ( $P=0.879$ ). After treatment, the IL-6 ( $18.69\pm 5.07$ , $P<0.001$ ) and IL-17 ( $30.67\pm 3.47$ , $P<0.001$ ) levels and HAMD scores ( $6.73\pm 4.15$ ) in the FDD group were significantly decreased than before treatment ( $P<0.001$ , respectively). CRP level was slightly increased after treatment without statistically significant ( $P=0.239$ ). The HAMD score correlated with IL-6 ( $r=0.638$ , $P<0.001$ ) and IL-17 ( $r=0.927$ , $P<0.001$ ); the total LES and negative LES also correlated with IL-6 ( $r=0.226$ , $P<0.05$ ) ( $r=0.366$ , P <0.001) and IL-17 ( $r=0.348$ , $P<0.001$ ) ( $r=0.493$ , $P<0.001$ ). Multiple linear regression analysis showed that both of the IL-6 and IL-17 had direct impact on HAMD score. Conclusion. The autoimmunity status was overactivated in FDD patients, and serum IL-6 and IL-17 levels had direct impact on the HAMD score. Patients who experienced more negative life events had higher activation level of autoimmunity status and HAMD scores, and serum IL-6 and IL-17 levels can be decreased by SSRI treatment.

The cost-effectiveness of depression screening for the general adult population

BACKGROUND

Depression is a treatable disease, and untreated depression can lead to serious health complications and decrease the quality of life. Therefore, prevention, early identification, and treatment efforts are essential. Screening has an essential role in preventive medicine in the general population. Ideally, screening tools detect patients early enough to manage the disease and reduce symptoms. We aimed to determine the cost-effectiveness of routine screening schedules.

METHODS

We used a discrete-time nonstationary Markov model to simulate the progression of depression. We used Monte Carlo techniques to simulate the stochastic model for 20 years or during the lifetime of individuals. Baseline and screening scenario models with screening frequencies of annual, 2-year, and 5-year strategies were compared based on incremental cost-effectiveness ratios (ICER). Monte Carlo (MC) simulation and one-way sensitivity analysis were conducted to manage uncertainties.

RESULTS

In the general population, all screening strategies were cost-effective compared to the baseline. However, male and female populations differed based on cost over quality-adjusted life years (QALY). Females had lower ICERs, and annual screening had the highest ICER for females, with 11,134$/QALY gained. In contrast, males had around three times higher ICER, with annual screening costs of 34,065$/QALY gained.

LIMITATIONS

We assumed that the screening frequency was not changing at any time during the screening scenario. In our calculations, false-positive cases were not taking into account.

CONCLUSIONS

Considering the high lifetime prevalence and recurrence rates of depression, detection and prevention efforts can be one critical cornerstone to support required care. Our analysis combined the expected benefits and costs of screening and assessed the effectiveness of screening scenarios. We conclude that routine screening is cost-effective for all age groups of females and young, middle-aged males.

Brain Networks Involved in Depression in Patients with Frontotemporal Dementia and Parkinson’s Disease: An Exploratory Resting-State Functional Connectivity MRI Study

Depression is characterized by feelings of sadness, loss, or anger that may interfere with everyday activities. Such a neuropsychiatric condition is commonly reported in multiple neurodegenerative disorders, which are quite different from each other. This study aimed at investigating the brain networks involved in depression in patients with frontotemporal dementia (FTD) and Parkinson’s disease (PD) as compared to healthy controls (HC). Fifty participants were included in the study: 17 depressed FTD/PD patients; 17 non-depressed FTD/PD patients; and 16 non-depressed HCs matched for age and gender. We used the Beck depression inventory (BDI-II) to measure depression in all groups. On the same day, 3T brain magnetic resonance with structural and resting-state functional sequences were acquired. Differences in resting-state functional connectivity (FC) between depressed and non-depressed patients in all the experimental groups were assessed by using seed-to-seed and network-to-network approaches. We found a significant seed-to-seed hyperconnectivity patterns between the left thalamus and the left posterior temporal fusiform cortex, which differentiated FTD/PD depressed patients from the HCs. Network-to-network analysis revealed a significant hyperconnectivity among the default-mode network (left lateral-parietal region), the medial prefrontal cortex and the left lateral prefrontal cortex (i.e., part of the central executive network). We investigated whether such FC patterns could be related to the underlying neurodegenerative disorder by replicating the analyses with two independent samples (i.e., non-depressed PD and non-depressed FTD patients) and adding clinical parameters as covariates. We found no FC differences in these groups, thus suggesting how the FC pattern we found may signal a common depression-related neural pathway implicated in both the neurocognitive disorders.

Depression and unplanned secondary healthcare use in patients with multimorbidity: A systematic review

Background

Growing numbers of people with multimorbidity have a co-occurring mental health condition such as depression. Co-occurring depression is associated with poor patient outcomes and increased healthcare costs including unplanned use of secondary healthcare which may be avoidable.

Aim

To summarise the current evidence on the association between depression and unplanned secondary healthcare use among patients with multimorbidity.

Methods

We conducted a systematic review by searching MEDLINE, EMBASE, PsychINFO, Web of Science, CINAHL, and Cochrane Library from January 2000 to March 2021. We included studies on adults with depression and at least one other physical long-term condition that examined risk of emergency hospital admissions as a primary outcome, alongside emergency department visits or emergency readmissions. Studies were assessed for risk of bias using The National Institute of Health National Heart, Lung, and Blood Institute quality assessment tool. Relevant data were extracted from studies and a narrative synthesis of findings produced.

Results

Twenty observational studies were included in the review. Depression was significantly associated with different outcomes of unplanned secondary healthcare use, across various comorbidities. Among the studies examining these outcomes, depression predicted emergency department visits in 7 out of 9 studies; emergency hospital admissions in 19 out of 20 studies; and emergency readmissions in 4 out of 4 studies. This effect increased with greater severity of depression. Other predictors of unplanned secondary care reported include increased age, being female, and presence of greater numbers of comorbidities.

Conclusion

Depression predicted increased risk of unplanned secondary healthcare use in individuals with multimorbidity. The literature indicates a research gap in identifying and understanding the impact of complex multimorbidity combinations, and other patient characteristics on unplanned care in patients with depression. Findings indicate the need to improve planned care for patients with moderate-to-severe depression. We suggest regular reviews of care plans, depression severity monitoring and assessment of hospital admission risk in primary care settings.

Preliminary investigation of Shift, a novel smartphone application to support junior doctors’ mental health and wellbeing: Examination of symptom progression, usability, and acceptability after one month of use (Preprint)

Background

Shift is a novel smartphone app for providing a digital-first mental health resource to junior doctors. It contains psychoeducational material, cognitive behavioral modules, guided mediations, information on common work stressors, and a section on help-seeking options for psychological problems through workplace and private avenues.

Objective

This study aimed to conduct a preliminary investigation of the use and potential effectiveness of Shift on depressive and anxiety symptoms (primary outcomes) and work and social functioning, COVID-19 safety concerns, and help seeking (secondary outcomes). This study also sought feedback on whether Shift was seen as an acceptable tool.

Methods

Junior doctors in New South Wales, Australia, were approached through promotional activities from the Ministry of Health, specialist medical colleges, and social media advertisements between June and August 2020. Consenting participants provided web-based baseline data, used the Shift app for 30 days, and were asked to complete a poststudy web-based questionnaire. Outcomes were analyzed under the intention-to-treat principle.

Results

A total of 222 female (n=156, 70.3%; mean age 29.2, SD 4.61 years) junior doctors provided full baseline data. Of these, 89.2% (198/222) downloaded the app, logged into the app approximately 6 times (mean 5.68, SD 7.51), completed 4 in-app activities (mean 3.77, SD 4.36), and spent a total of 1 hour on in-app activities (mean 52:23, SD 6:00:18) over 30 days. Postintervention and app use data were provided by 24.3% (54/222) of participants. Depressive and anxiety symptoms significantly decreased between the pre- and postassessment points as expected; however, physicians’ COVID-19 safety concerns significantly increased. Work and social functioning, COVID-19 concerns for family and friends, and help seeking did not change significantly. There was no significant relationship between symptom changes and app use (number of log-ins, days between first and last log-in, and total activity time). Most poststudy completers (31/54, 57%) rated Shift highly or very highly.

Conclusions

Despite high levels of nonresponse to the poststudy assessment and increases in COVID-19 safety concerns, junior doctors who used the app reported some improvements in depression and anxiety, which warrant further exploration in a robust manner.

White matter fiber microstructure is associated with prior hospitalizations rather than acute symptomatology in major depressive disorder

BACKGROUND

Eighty percent of all patients suffering from major depressive disorder (MDD) relapse at least once in their lifetime. Thus, understanding the neurobiological underpinnings of the course of MDD is of utmost importance. A detrimental course of illness in MDD was most consistently associated with superior longitudinal fasciculus (SLF) fiber integrity. As similar associations were, however, found between SLF fiber integrity and acute symptomatology, this study attempts to disentangle associations attributed to current depression from long-term course of illness.

METHODS

A total of 531 patients suffering from acute (N = 250) or remitted (N = 281) MDD from the FOR2107-cohort were analyzed in this cross-sectional study using tract-based spatial statistics for diffusion tensor imaging. First, the effects of disease state (acute v. remitted), current symptom severity (BDI-score) and course of illness (number of hospitalizations) on fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity were analyzed separately. Second, disease state and BDI-scores were analyzed in conjunction with the number of hospitalizations to disentangle their effects.

RESULTS

Disease state (p_FWE < 0.042) and number of hospitalizations (p_FWE< 0.032) were associated with decreased FA and increased MD and RD in the bilateral SLF. A trend was found for the BDI-score (p_FWE > 0.067). When analyzed simultaneously only the effect of course of illness remained significant (p_FWE < 0.040) mapping to the right SLF.

CONCLUSIONS

Decreased FA and increased MD and RD values in the SLF are associated with more hospitalizations when controlling for current psychopathology. SLF fiber integrity could reflect cumulative illness burden at a neurobiological level and should be targeted in future longitudinal analyses.

Sex differences in the blood-brain barrier: Implications for mental health

Prevalence of mental disorders, including major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SZ) are increasing at alarming rates in our societies. Growing evidence points toward major sex differences in these conditions, and high rates of treatment resistance support the need to consider novel biological mechanisms outside of neuronal function to gain mechanistic insights that could lead to innovative therapies. Blood-brain barrier alterations have been reported in MDD, BD and SZ. Here, we provide an overview of sex-specific immune, endocrine, vascular and transcriptional-mediated changes that could affect neurovascular integrity and possibly contribute to the pathogenesis of mental disorders. We also identify pitfalls in current literature and highlight promising vascular biomarkers. Better understanding of how these adaptations can contribute to mental health status is essential not only in the context of MDD, BD and SZ but also cardiovascular diseases and stroke which are associated with higher prevalence of these conditions.

Developing symptom clusters: linking inflammatory biomarkers to depressive symptom profiles

Considering the burden of depression and the lack of efficacy of available treatments, there is a need for biomarkers to predict tailored or personalized treatments. However, identifying reliable biomarkers for depression has been challenging, likely owing to the vast symptom heterogeneity and high rates of comorbidity that exists. Examining biomarkers that map onto dimensions of depression as well as shared symptoms/constructs that cut across disorders could be most effective for informing personalized treatment approaches. With a sample of 539 young adults, we conducted a principal component analysis (PCA) followed by hierarchical cluster analysis to develop transdiagnostic clusters of depression and anxiety symptoms. We collected blood to assess whether neuroendocrine (cortisol) and inflammatory profiles (C-reactive protein (CRP), Interleukin (IL)-6, and tumor necrosis factor (TNF) - α) could be used to differentiate symptom clusters. Six distinct clusters were identified that differed significantly on symptom dimensions including somatic anxiety, general anxiety, anhedonia, and neurovegetative depression. Moreover, the neurovegetative depression cluster displayed significantly elevated CRP levels compared to other clusters. In fact, inflammation was not strongly associated with overall depression scores or severity, but rather related to specific features of depression marked by eating, appetite, and tiredness. This study emphasizes the importance of characterizing the biological underpinnings of symptom dimensions and subtypes to better understand the etiology of complex mental health disorders such as depression.

Activation of the 5-HT7 receptor and MMP-9 signaling module in the hippocampal CA1 region is necessary for the development of depressive-like behavior

Major depressive disorder is a complex disease resulting from aberrant synaptic plasticity that may be caused by abnormal serotonergic signaling. Using a combination of behavioral, biochemical, and imaging methods, we analyze 5-HT7R/MMP-9 signaling and dendritic spine plasticity in the hippocampus in mice treated with the selective 5-HT7R agonist (LP-211) and in a model of chronic unpredictable stress (CUS)-induced depressive-like behavior. We show that acute 5-HT7R activation induces depressive-like behavior in mice in an MMP-9-dependent manner and that post mortem brain samples from human individuals with depression reveal increased MMP-9 enzymatic activity in the hippocampus. Both pharmacological activation of 5-HT7R and modulation of its downstream effectors as a result of CUS lead to dendritic spine elongation and decreased spine density in this region. Overall, the 5-HT7R/MMP-9 pathway is specifically activated in the CA1 subregion of the hippocampus during chronic stress and is crucial for inducing depressive-like behavior.

Evidence on sociodemographic and clinical correlates of antidepressant combination or augmentation with second-generation antipsychotics in major depressive disorder

About two thirds of the patients with major depressive disorder (MDD) do not sufficiently respond to monotherapy with antidepressants (ADs) which makes them reliant on further treatment approaches. Hereby, combination of different ADs and augmentation with second-generation antipsychotics (SGAs) are widely used and recommended psychopharmacotherapeutic strategies. The present secondary analyses are based on an international, naturalistic, cross-sectional multicenter study conducted by the European Group for the Study of Resistant Depression. Comparing socio-demographic and clinical characteristics of 436 adult MDD patients receiving either SGAs (N = 191, 43.8%) or ADs (N = 245, 56.2%), that were additionally administered to their first-line AD psychopharmacotherapy, we aimed to identify possible trajectories of decision-making for clinicians regarding which treatment option to prefer in individual patients. Our most robust findings represent an association of SGA augmentation with the presence of psychotic symptoms, longer mean duration of lifetime psychiatric hospitalizations, employment of further augmentation strategies with mood-stabilizers and benzodiazepines, and a trend towards higher mean daily dosages of their first-line ADs and current suicidal risk. Treatment outcome was not significantly different between patients receiving either SGA augmentation or AD combination. Being aware of limitations inherent to the cross-sectional study design and the lack of randomization, more severe and rather chronic conditions in MDD seemed to encourage clinicians to choose SGA augmentation over AD combination. The fact that mood-stabilizers and/or benzodiazepines were more frequently co-administered with SGAs may represent a requirement of an overall refined psychopharmacotherapy including additional fast-acting agents with potent AD, tranquilizing and anti-suicidal effects in MDD patients experiencing challenging clinical manifestations. New glutamatergic substances seem to be promising in this regard.

Characterizing primary care for patients with major depressive disorder using electronic health records of a US-based healthcare provider

BACKGROUND

Major depressive disorder (MDD) is predominantly managed in primary care. However, primary care providers (PCPs) may not consistently follow evidence-based treatment algorithms, leading to variable patient management that can impact outcomes.

METHODS

We retrospectively analyzed adult patients with MDD seen at Geisinger, an integrated health system. Utilizing electronic health record (EHR) data, we classified patients as having MDD based on International Classification of Disease (ICD)-9/10 codes or a Patient Health Questionnaire (PHQ)-9 score ≥5. Outcomes assessed included time to first visit with a PCP or behavioral health specialist following diagnosis, antidepressant medication switching, persistence, healthcare resource utilization (HRU), and treatment costs.

RESULTS

Among the 38,321 patients with MDD managed in primary care in this study, significant delays between diagnosis with antidepressant prescribing and follow-up PCP visits were observed. There was also considerable variation in care following diagnosis. Overall, 34.9% of patients with an ICD-9/10 diagnosis of MDD and 41.3% with a PHQ-9 score ≥15 switched antidepressants. An ICD-9/10 diagnosis, but not moderately severe to severe depression, was associated with higher costs and HRU. More than 75% of patients with MDD discontinued antidepressant medication within 6 months.

LIMITATIONS

The study population was comparable with other real-world studies of MDD, but study limitations include its retrospective nature and reliance on the accuracy of EHRs.

CONCLUSIONS

Management of patients with MDD in a primary care setting is variable. Addressing these gaps will have important implications for ensuring optimal patient management, which may reduce HRU and treatment medication costs, and improve treatment persistence.

Electroencephalographic Signature of Negative Self Perceptions in Medical Students

Frontal alpha asymmetry (fAA) is purported to be a neurophysiological marker for anxiety and depression. Higher left frontal alpha EEG voltage is associated with lower left and higher right frontal cerebral cortical activation, indicative of right-sided fAA. This pilot study tests the hypothesis that greater left-sided frontal alpha voltage is associated with negative thoughts about oneself. A group of eight healthy 28-41-year-old right-handed male medical students were subjected to an extensive interactive self-report inventory (ISI) evaluating perceptions of their psychosocial interactions. Quantitative EEG (qEEG) was performed with eyes closed. Computations of fAA and related parameters were based on measurements in the alpha bandwidth (8-13 Hz) at the left frontal F7 and right frontal F8 scalp electrodes. fAA was the percent difference between mean voltages at F8 minus that at F7. Significance of associations between fAA and the ISI scores was determined by Pearson’s product-moment correlation coefficient, at P≤0.05. “Depressed” scores were positively correlated with right-sided fAA (P=0.01). “Relaxed” (P=0.05), “regulated” (P=0.02), “cooperative” (P=0.05) and “dependent scores” (P=0.004) were negatively correlated with right-sided fAA. These findings imply that right-sided fAA may be associated with more perceptions of “depressed” psychosocial interactions involving negative thoughts about oneself, as well as, more reliance on others (“dependence” score), less sharing (“cooperative” ISI score), less trust (“regulated” ISI score) and less initiative (“relaxed” ISI score). These results support the hypothesis that right-sided fAA may identify individuals with a predilection for negative thoughts about themselves and other negatively-valenced perceptions of their psychosocial interactions.

Pharmacogenomics-Guided Pharmacotherapy in Patients with Major Depressive Disorder or Bipolar Disorder Affected by Treatment-Resistant Depressive Episodes: A Long-Term Follow-up Study

Treatment-resistant depression (TRD) reduces affected patients’ quality of life and leads to important social health care costs. Pharmacogenomics-guided treatment (PGT) may be effective in the cure of TRD. The main aim of this study was to evaluate the clinical changes after PGT in patients with TRD (two or more recent failed psychopharmacological trials) affected by bipolar disorder (BD) or major depressive disorder (MDD) compared to a control group with treatment as usual (TAU). We based the PGT on assessing different gene polymorphisms involved in the pharmacodynamics and pharmacokinetics of drugs. We analyzed, with a repeated-measure ANOVA, the changes between the baseline and a 6 month follow-up of the efficacy index assessed through the Clinical Global Impression (CGI) scale, and depressive symptoms through the Hamilton Depression Rating Scale (HDRS). The PGT sample included 53 patients (26 BD and 27 MDD), and the TAU group included 52 patients (31 BD and 21 MDD). We found a significant within-subject effect of treatment time on symptoms and efficacy index for the whole sample, with significant improvements in the efficacy index (F = 8.544; partial η² = 0.077, p < 0.004) and clinical global impression of severity of illness (F = 6.818; partial η² = 0.062, p < 0.01) in the PGT vs. the TAU group. We also found a significantly better follow-up response (χ² = 5.479; p = 0.019) and remission (χ² = 10.351; p = 0.001) rates in the PGT vs. the TAU group. PGT may be an important option for the long-term treatment of patients with TRD affected by mood disorders, providing information that can better define drug treatment strategies and increase therapeutic improvement.

Integrative Functional, Molecular, and Transcriptomic Analyses of Altered Intrinsic Timescale Gradient in Depression

The pathophysiology and pharmacology of depression are hypothesized to be related to the imbalance of excitation–inhibition that gives rise to hierarchical dynamics (or intrinsic timescale gradient), further supporting a hierarchy of cortical functions. On this assumption, intrinsic timescale gradient is theoretically altered in depression. However, it remains unknown. We investigated altered intrinsic timescale gradient recently developed to measure hierarchical brain dynamics gradient and its underlying molecular architecture and brain-wide gene expression in depression. We first presented replicable intrinsic timescale gradient in two independent Chinese Han datasets and then investigated altered intrinsic timescale gradient and its possible underlying molecular and transcriptional bases in patients with depression. As a result, patients with depression showed stage-specifically shorter timescales compared with healthy controls according to illness duration. The shorter timescales were spatially correlated with monoamine receptor/transporter densities, suggesting the underlying molecular basis of timescale aberrance and providing clues to treatment. In addition, we identified that timescale aberrance-related genes ontologically enriched for synapse-related and neurotransmitter (receptor) terms, elaborating the underlying transcriptional basis of timescale aberrance. These findings revealed atypical timescale gradient in depression and built a link between neuroimaging, transcriptome, and neurotransmitter information, facilitating an integrative understanding of depression.

New Insights Into the Pivotal Role of CREB-Regulated Transcription Coactivator 1 in Depression and Comorbid Obesity

Depression and obesity are major public health concerns, and there is mounting evidence that they share etiopathophysiological mechanisms. The neurobiological pathways involved in both mood and energy balance regulation are complex, multifactorial and still incompletely understood. As a coactivator of the pleiotropic transcription factor cAMP response element-binding protein (CREB), CREB-regulated transcription coactivator 1 (CRTC1) has recently emerged as a novel regulator of neuronal plasticity and brain functions, while CRTC1 dysfunction has been associated with neurodegenerative and psychiatric diseases. This review focuses on recent evidence emphasizing the critical role of CRTC1 in the neurobiology of depression and comorbid obesity. We discuss the role of CRTC1 downregulation in mediating chronic stress-induced depressive-like behaviors, and antidepressant response in the light of the previously characterized Crtc1 knockout mouse model of depression. The putative role of CRTC1 in the alteration of brain energy homeostasis observed in depression is also discussed. Finally, we highlight rodent and human studies supporting the critical involvement of CRTC1 in depression-associated obesity.

A novel 4 immune-related genes as diagnostic markers and correlated with immune infiltrates in major depressive disorder

Background

Immune response is prevalently related with major depressive disorder (MDD) pathophysiology. However, the study on the relationship between immune-related genes (IRGs) and immune infiltrates of MDD remains scarce.

Methods

We extracted expression data of 148 MDD patients from 2 cohorts, and systematically characterized differentially expressed IRGs by using limma package in R software. Then, the LASSO and multivariate logistic regression analysis was used to identify the most powerful IRGs. Next, we analyzed the relationship between IRGs and immune infiltrates of MDD. Finally, GSE76826 was used to to verificate of IRGs as a diagnostic markers in MDD.

Results

203 different IRGs s in MDD has been identified (P < 0.05). GSEA revealed that the different IRGs was more likely to be enriched in immune-specific pathways. Then, a 9 IRGs was successfully established to predict MDD based on LASSO. Next, 4 IRGs was obtained by multivariate logistic regression analysis, and AUC for CD1C, SPP1, CD3D, CAMKK2, and IRGs model was 0.733, 0.767, 0.816, 0.800, and 0.861, suggesting that they have a good diagnostic performance. Furthermore, the proportion of T cells CD8, T cells γδ, macrophages M0, and NK cells resting in MDD group was lower than that in the healthy controls, suggesting that the immune system in MDD group is impaired. Simultaneously, CD3D was validated a reliable marker in MDD, and was positively correlated with T cells CD8. GSEA revealed high expression CD3D was more likely to be enriched in immune-specific pathways, and low expression CD3D was more likely to be enriched in glucose metabolism metabolism-specific pathways.

Conclusions

We applied bioinformatics approaches to suggest that a 4 IRGs could serve as diagnostic markers to provide a novel direction to explore the pathogenesis of MDD.

Translational Informatics for Natural Products as Antidepressant Agents

Depression, a neurological disorder, is a universally common and debilitating illness where social and economic issues could also become one of its etiologic factors. From a global perspective, it is the fourth leading cause of long-term disability in human beings. For centuries, natural products have proven their true potential to combat various diseases and disorders, including depression and its associated ailments. Translational informatics applies informatics models at molecular, imaging, individual, and population levels to promote the translation of basic research to clinical applications. The present review summarizes natural-antidepressant-based translational informatics studies and addresses challenges and opportunities for future research in the field.

Digital health tools for the passive monitoring of depression: a systematic review of methods

The use of digital tools to measure physiological and behavioural variables of potential relevance to mental health is a growing field sitting at the intersection between computer science, engineering, and clinical science. We summarised the literature on remote measuring technologies, mapping methodological challenges and threats to reproducibility, and identified leading digital signals for depression. Medical and computer science databases were searched between January 2007 and November 2019. Published studies linking depression and objective behavioural data obtained from smartphone and wearable device sensors in adults with unipolar depression and healthy subjects were included. A descriptive approach was taken to synthesise study methodologies. We included 51 studies and found threats to reproducibility and transparency arising from failure to provide comprehensive descriptions of recruitment strategies, sample information, feature construction and the determination and handling of missing data. The literature is characterised by small sample sizes, short follow-up duration and great variability in the quality of reporting, limiting the interpretability of pooled results. Bivariate analyses show consistency in statistically significant associations between depression and digital features from sleep, physical activity, location, and phone use data. Machine learning models found the predictive value of aggregated features. Given the pitfalls in the combined literature, these results should be taken purely as a starting point for hypothesis generation. Since this research is ultimately aimed at informing clinical practice, we recommend improvements in reporting standards including consideration of generalisability and reproducibility, such as wider diversity of samples, thorough reporting methodology and the reporting of potential bias in studies with numerous features.

Treatment-Resistant Depression in Portugal: Perspective From Psychiatry Experts

Guidance about treatment-resistant depression (TRD) in Portugal is very limited, even though depression prevalence is among the highest in European countries. A questionnaire was conducted, followed by two advisory boards with seven Portuguese psychiatry experts, to characterize and discuss MDD and TRD epidemiology, diagnosis, patient journey, treatment options, and unmet clinical needs. Consensus was reached on the main issues. In daily practice, TRD can be defined as moderate to severe MDD episodes with insufficient clinical improvement after two antidepressant treatments, taken in adequate doses and duration. TRD diagnosis and treatment are mostly decided by psychiatrists at public hospitals. Treatment type and duration must be adjusted to characteristics of the patient and the depressive episode, including symptoms, number of previous episodes, comorbidities, and previous treatment response and side effects. The most relevant objectives of TRD treatment are reaching response and remission, prevention of suicide, and improvement of quality of life, functionality, and wellbeing. Regarding pharmacotherapy, antidepressant switch occurs more frequently with non-response, while optimization, combination, and augmentation are considered for patients with partial response. Psychotherapy should be considered in parallel to pharmacological treatment. Brain stimulation techniques are underused. Lifelong treatment is required for recurrent or more chronic TRD episodes, but patient adherence is also poorer in these cases. In Portugal, TRD management is limited by lack of access to specialist care and to many treatment options. These aspects highlight that conventional pharmacotherapy does not lead to remission in many patients and that optimization strategies are frequently necessary to achieve satisfactory treatment outcomes.

Predicting escitalopram treatment response from pre-treatment and early response resting state fMRI in a multi-site sample: A CAN-BIND-1 report

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Baseline measures alone not able to predict escitalopram response above default.

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This poor baseline performance contradicts results from smaller studies.

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Accuracy improved using change in functional connectivity from baseline to week 2.

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Measures of early change following treatment may be crucial for accurate prediction.

Many previous intervention studies have used functional magnetic resonance imaging (fMRI) data to predict the antidepressant response of patients with major depressive disorder (MDD); however, practical constraints have limited many of those attempts to small, single centre studies which may not adequately reflect how these models will generalize when used in clinical practice. Not only does the act of collecting data at multiple sites generally increase sample sizes (a critical point in machine learning development) it also generates a more heterogeneous dataset due to systematic differences in scanners at different sites, and geographical differences in patient populations. As part of the Canadian Biomarker Integration Network in Depression (CAN-BIND-1) study, 144 MDD patients from six sites underwent resting state fMRI prior to starting escitalopram treatment, and again two weeks after the start. Here, we consider ways to use machine learning techniques to produce models that can predict response (measured at eight weeks after initiation), based on various parcellations, functional connectivity (FC) metrics, dimensionality reduction algorithms, and base learners, and also whether to use scans from one or both time points. Models that use only baseline (pre-treatment) or only week 2 (early-response) whole-brain FC features consistently failed to perform significantly better than default models. Utilizing the change in FC between these two time points, however, yielded significant results, with the best performing analytical pipeline achieving 69.6% (SD 10.8) accuracy. These results appear contrary to findings from many smaller single-site studies, which report substantially higher predictive accuracies from models trained on only baseline resting state FC features, suggesting these models may not generalize well beyond data used for development. Further, these results indicate the potential value of collecting data both before and shortly after treatment initiation.

The Toxicity Potential of Antidepressants and Antipsychotics in Relation to Other Medication and Alcohol: A Naturalistic and Retrospective Study

QT interval prolongation and ventricular tachyarrhythmia are potential adverse effects of antidepressant (AD) and antipsychotic- (AP) agents, especially when overdosed. Since AD and AP agents are often prescribed to patients suffering from suicidal intentions, it is essential to estimate these risks in the context of intoxications. This retrospective and naturalistic one-year registry study included 105 patients treated for oral intoxication at the University Department of Emergency Medicine in Vienna, Austria. AD/AP intoxications were present in 26 patients, while in the control group (n = 79) non-AD/AP drugs (n = 54) and exclusively alcohol (n = 25) were the toxic agents. QT intervals, the necessity of intubation, the extent of conscious state, and the subsequent discharge management were compared. The mean age was 34.94 ± 14.6 years, 62 patients (59%) were female. There were no significant between-group differences regarding QT prolongation >470 ms using Bazett's correction (p = 0.178), or >440 ms using Fridericia's correction (p = 0.760). No significant group differences concerning the need for intubation were observed (p = 0.747). The AD/AP and the control group did not significantly differ regarding Glasgow Coma Scale scores (p = 0.439). Patients with AD/AP intoxication were significantly more often transferred to the psychiatric department, while discharge to home was more likely in the control group (p = 0.002). These results suggest that the risk of a potentially life-threatening outcome in cases of intoxication with AD/AP is not substantially higher than in other easily available toxic agents, in line with the advantageous risk/benefit ratio of newer ADs and APs.

The sociodemographic and clinical profile of patients with major depressive disorder receiving SSRIs as first-line antidepressant treatment in European countries

INTRODUCTION

Due to favorable antidepressant (AD) efficacy and tolerability, selective-serotonin reuptake inhibitors (SSRIs) are consistently recommended as substances of first choice for the treatment of major depressive disorder (MDD) in international guidelines. However, little is known about the real-world clinical correlates of patients primarily prescribed SSRIs in contrast to those receiving alternative first-line ADs.

METHODS

These secondary analyses are based on a naturalistic, multinational cross-sectional study conducted by the European Group for the Study of Resistant Depression at ten research sites. We compared the socio-demographic and clinical characteristics of 1410 patients with primary MDD, who were either prescribed SSRIs or alternative substances as first-line AD treatment, using chi-squared tests, analyses of covariance, and logistic regression analyses.

RESULTS

SSRIs were prescribed in 52.1% of MDD patients who showed lower odds for unemployment, current severity of depressive symptoms, melancholic features, suicidality, as well as current inpatient treatment compared to patients receiving alternative first-line ADs. Furthermore, patients prescribed SSRIs less likely received add-on therapies including AD combination and augmentation with antipsychotics, and exhibited a trend towards higher response rates.

CONCLUSION

A more favorable socio-demographic and clinical profile associated with SSRIs in contrast to alternative first-line ADs may have guided European psychiatrists' treatment choice for SSRIs, rather than any relevant pharmacological differences in mechanisms of action of the investigated ADs. Our results must be cautiously interpreted in light of predictable biases resulting from the open treatment selection, the possible allocation of less severely ill patients to SSRIs as well as the cross-sectional study design that does not allow to ascertain any causal conclusions.

A Southeast Asia Consensus on the Definition and Management of Treatment-Resistant Depression

INTRODUCTION

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD and available treatment pathways for the management of TRD vary across the Southeast Asia (SEA) region, highlighting the need for a uniform definition and treatment principles to optimize the management TRD in SEA.

METHODS

Following a thematic literature review and pre-meeting survey, a SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA Appropriateness Method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management.

RESULTS

The expert panel agreed that "pharmacotherapy-resistant depression" (PRD) is a more suitable term for TRD and defined it as "failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode". A stepwise treatment approach should be employed for the management of PRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Non-pharmacological treatments, such as electroconvulsive therapy and repetitive transcranial magnetic stimulation, are also appropriate options for patients with PRD.

CONCLUSION

These consensus recommendations on the operational definition of PRD and treatment principles for its management can be adapted to local contexts in the SEA countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with PRD.

Volatile Organic Compounds From Breath Differ Between Patients With Major Depression and Healthy Controls

Major depressive disorder (MDD) is a widespread common disorder. Up to now, there are no easy and frequent to use non-invasive biomarkers that could guide the diagnosis and treatment of MDD. The aim of this study was to investigate whether there are different mass concentrations of volatile organic compounds (VOCs) in the exhaled breath between patients with MDD and healthy controls. For this purpose, patients with MDD according to DSM-V and healthy subjects were investigated. VOCs contained in the breath were collected immediately after awakening, after 30 min, and after 60 min in a respective breath sample and measured using PRT-MS (proton-transfer-reaction mass spectrometry). Concentrations of masses m/z 88, 89, and 90 were significantly decreased in patients with MDD compared with healthy controls. Moreover, changes during the time in mass concentrations of m/z 93 and 69 significantly differed between groups. Differentiation between groups was possible with an AUCs of 0.80-0.94 in ROC analyses. In this first study, VOCs differed between patients and controls, and therefore, might be a promising tool for future studies. Altered masses are conceivable with energy metabolism in a variety of biochemical processes and involvement of the brain-gut-lung-microbiome axis.

Effect of Personality Traits on Sustained Remission Among Patients with Major Depression: A 12-Month Prospective Study

PURPOSE

Major depression is a heterogeneous disorder. Therefore, careful evaluation and comprehensive assessment are crucial elements for achieving remission. Personality traits influence prognosis and treatment outcomes, but there is not enough evidence on the association between personality traits and sustained remission (SR). Hence, the present study aimed to evaluate the relationship between personality traits and SR among patients with major depression.

PATIENTS AND METHODS

The 12-month prospective study evaluated 77 patients diagnosed with major depressive disorder. All patients underwent a comprehensive assessment, including the Temperament and Personality Questionnaire (T&P) at baseline, and depression severity was measured at baseline as well as six and 12 months. SR was defined as remission (the GRID-Hamilton Depression Rating Scale [GRID-HAMD₁₇] score ≦ 7) at both the 6- and 12-month follow-up. We compared eight T&P construct scores at baseline between the SR and non-SR groups. Multivariable logistic regression analyses were performed to determine the T&P personality traits related to SR.

RESULTS

Patients who achieved SR had a lower T&P personal reserve and lower T&P rejection sensitivity. Further, lower scores on the T&P personal reserve trait were independently associated with higher rates of SR among patients with major depression. Patients who achieved SR had a shorter duration of the current depressive episode and milder severity of depression at baseline.

CONCLUSION

A lower level of personal reserve predicted a higher probability of SR in the treatment of depression. Extended observations in naturalistic follow-up settings with larger sample sizes are required to better understand the personality traits affecting SR in patients with depression.

Profiling classical neuropsychiatric biomarkers across biological fluids and following continuous lumbar puncture: A guide to sample type and time

Identification of putative biomarkers for neuropsychiatric disorders has produced a diverse list of analytes involved in inflammation, hypothalamic–pituitary–adrenal axis (HPA) regulation, growth factor and metabolic pathways. However, translation of these findings to accurate and robust assays has been stalled, affecting objective diagnoses, tracking relapse/remission, and prediction/monitoring of drug affect. Two important factors to control are the sample matrix (e.g. serum, plasma, saliva, or cerebrospinal fluid) and time of sample collection. Additionally, sample collection procedures may affect analyte level. In this study, a panel of 14 core neuropsychiatric biomarkers was measured in serum, plasma, saliva, and cerebrospinal fluid (CSF), all collected from 8 healthy volunteers at the same time. In a second cohort of 7 healthy volunteers, 6 analytes were measured in serum and CSF collected at 13 timepoints over a 24-h period after catheter placement. We found that many of the analytes were quantifiable in all sample types examined, but often at quite different concentrations and without correlation between the sample types. After catheter placement, a diurnal pattern was observed for cortisol and interleukin-6 in serum, and transient spikes were observed in interleukin-1β. In CSF, a chronic elevation of several cytokines was observed instead, perhaps due to the continuous sampling procedure. These findings enable more informed decision-making around sample type and collection time, which can be implemented in future biomarker studies.

Clinicaltrial.gov identifiers

NCT02933762, NCT02475148.

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Diurnal pattern for cortisol, interleukin (IL)-6 and transient spikes for IL-1β were observed

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Chronic elevation of cytokines observed may be due to continuous sampling procedure

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Informed decision-making around sample types and collection time can be implemented

The well-being of older age Lithuanians: Policy implications

Many countries of the world consider the well-being of citizens to be one of their most important goals. Nowadays there is a growing concern about the well-being of older people. Considering the aging population, there is a call for social policies aimed at strengthening the well-being of older people. Therefore, recommendations were prepared for policymakers on possible ways to strengthen the well-being of the older age Lithuanian population. The recommendations are based on data from the 7th wave of the Survey of Health, Aging, and Retirement in Europe (SHARE). There were 2014 persons aged 50 and older interviewed in Lithuania in the 7th wave of the SHARE survey. Data on various aspects of well-being, health, work and economic situation, childhood circumstances, experiences of discrimination were analyzed. Based on different aspects of well-being it was found, that respondents can be grouped into high, low, and medium well-being clusters, moreover the analysis showed that the Lithuanian population has relatively low well-being compared to other countries. Recommendations were formulated covering possible measures for chronic diseases, co-morbid mental health disorders, work, economic situation, childhood environment, and personal life history. The recommendations are addressed to health, social and employment, education, and science policymakers.

Functional stability predicts depressive and cognitive improvement in major depressive disorder: A longitudinal functional MRI study

Functional stability is a newly developed dynamic functional connectivity approach. The objective of this study was to adopt functional stability to investigate diagnosis-associated abnormalities (patients vs. controls) and status-related changes (acute vs. remitted status) in brain function in major depressive disorder (MDD). 132 MDD patients and 102 healthy controls underwent resting-state functional MRI as well as clinical and cognitive assessment at baseline, with 48 patients completing follow-up examinations at an average of 7 months. Results showed no group differences in baseline functional stability and no longitudinal functional stability changes from acute to remitted status in patients. However, we found that baseline functional stability in the dorsal and ventral anterior cingulate cortex, calcarine sulcus, and middle occipital gyrus could predict improvement in depressive symptoms from acute to remitted status in MDD patients, with longitudinal functional stability changes in these regions related to the degree of symptom improvement. In addition, lower baseline functional stability in the inferior temporal gyrus could predict a greater improvement in sustained attention, which was associated with a greater functional stability increase in this region. Our findings highlight functional stability as a potential prognostic biomarker to predict and track disease progression or stratify MDD patients for optimizing disease management and treatment strategies.