Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 1. Disease Burden and Principles of Care

How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations

Adherence to antidepressants is crucial for optimal treatment outcomes when treating depressive disorders. However, poor adherence is common among patients prescribed antidepressants. This targeted review summarizes the main factors associated with poor adherence, interventions that promote antidepressant adherence, pharmacological aspects related to antidepressant adherence, and formulates 10 clinical recommendations to optimize antidepressant adherence. Patient-related factors associated with antidepressant non-adherence include younger age, psychiatric and medical comorbidities, cognitive impairment, and substance use disorders. Prescriber behavior-related factors include neglecting medical and family histories, selecting poorly tolerated antidepressants, or complex antidepressant regimens. Multi-disciplinary interventions targeting both patient and prescriber, aimed at improving antidepressant adherence, include psychoeducation and providing the patient with clear behavioral interventions to prevent/minimize poor adherence. Regarding antidepressant choice, agents with individually tailored tolerability profile should be chosen. Ten clinical recommendations include four points focusing on the patient (therapeutic alliance, adequate history taking, measurement of depressive symptoms, and adverse effects improved access to clinical care), three focusing on prescribing practice (psychoeducation, individually tailored antidepressant choice, simplified regimen), two focusing on mental health services (improved access to mental health care, incentivized adherence promotion and monitoring), and one relating to adherence measurement (adherence measurement with scales and/or therapeutic drug monitoring).

Association of treatment facets, severity of manic symptoms, psychomotor disturbances and psychotic features with response to electroconvulsive therapy in bipolar depression

OBJECTIVES

Clinically useful predictors of response to electroconvulsive therapy (ECT) are warranted, especially in the case of bipolar depression. The aim of this study was to explore the associations between response and its known and putative correlates.

METHODS

Six hundred seventy bipolar depressive patients treated with ECT were included in the study. The association between response (CGI-I ≤ 2) and mean seizure duration, number of treatments, age, sex, bipolar subtype, episode duration, HAM-D and YMRS scores, psychomotor disturbances and psychotic symptoms assessed through BPRS-EV were evaluated by means of univariate and multivariate logistic regression models, including quadratic and/or linear effects of continuous variables.

RESULTS

Four hundred eighty three patients (72%) were responders. Among known correlates of response, significant quadratic effects were found for seizure duration and number of treatments, while a linear association was confirmed for episode duration. Among putative correlates, severe motor retardation, tension or agitation, hyperactivity and delusions of guilt were significantly associated with response (p<.01) and a significant quadratic effect was found for YMRS score (p<.01).

CONCLUSION

Bipolar depressive patients with severe psychomotor disturbances, mood-congruent delusions and severe mixed features are highly responsive to ECT. A significant improvement in response prediction is expected when considering those clinical characteristics.

Nitrous oxide as an adjunctive therapy in major depressive disorder: a randomized controlled double-blind pilot trial

OBJECTIVE

Major depressive disorder (MDD) is related to glutamatergic dysfunction. Antagonists of glutamatergic N-methyl-D-aspartate receptor (NMDAR), such as ketamine, have antidepressant properties. Nitrous oxide (N2O) is also a NMDAR antagonist. Thus, this study aimed to evaluate the effects of augmenting antidepressant treatment with N2O.

METHODS

This double blind, placebo-controlled randomized parallel pilot trial was conducted from June 2016 to June 2018 at the Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Twenty-three subjects with MDD (aged 18 to 65, on antidepressants, with a score > 17 on the 17-item-Hamilton Depression Rating Scale [HAM-D17]) received 50% N2O (n=12; 37.17±13.59 years) or placebo (100% oxygen) (n=11; 37.18±12.77 years) for 60 minutes twice a week for 4 weeks. The primary outcome was changes in HAM-D17 from baseline to week 4.

RESULTS

Depressive symptoms improved significantly in the N2O group (N2O: from 22.58±3.83 to 5.92±4.08; placebo: from 22.44±3.54 to 12.89±5.39, p < 0.005). A total of 91.7% and 75% of the N2O group subjects achieved response (≥ 50% reduction in HAM-D17 score) and remission (HAM-D17 < 7), respectively. The predominant adverse effects of N2O treatment were nausea, vomiting, and headache.

CONCLUSION

N2O treatment led to a statistically significant reduction in HAM-D17 scores compared to placebo.

CLINICAL TRIAL REGISTRATION

Brazilian Register of Clinical Trials, RBR-5rz5ch.

Implementing Measurement-Based Care for Depression: Practical Solutions for Psychiatrists and Primary Care Physicians

Measurement-based care (MBC) can be defined as the clinical practice in which care providers collect patient data through validated outcome scales and use the results to guide their decision-making processes. Despite growing evidence supporting the effectiveness of MBC for depression and other mental health conditions, many physicians and mental health clinicians have yet to adopt MBC practice. In part, this is due to individual and organizational barriers to implementing MBC in busy clinical settings. In this paper, we briefly review the evidence for the efficacy of MBC focusing on pharmacological management of depression and provide example clinical scenarios to illustrate its potential clinical utility in psychiatric settings. We discuss the barriers and challenges for MBC adoption and then address these by suggesting simple solutions to implement MBC for depression care, including recommended outcome scales, monitoring tools, and technology solutions such as cloud-based MBC services and mobile health apps for mood tracking. The availability of MBC tools, ranging from paper-pencil questionnaires to mobile health technology, can allow psychiatrists and clinicians in all types of practice settings to easily incorporate MBC into their practices and improve outcomes for their patients with depression.

Using a simulation centre to evaluate preliminary acceptability and impact of an artificial intelligence-powered clinical decision support system for depression treatment on the physician-patient interaction

BACKGROUND

Recently, artificial intelligence-powered devices have been put forward as potentially powerful tools for the improvement of mental healthcare. An important question is how these devices impact the physician-patient interaction.

AIMS

Aifred is an artificial intelligence-powered clinical decision support system (CDSS) for the treatment of major depression. Here, we explore the use of a simulation centre environment in evaluating the usability of Aifred, particularly its impact on the physician-patient interaction.

METHOD

Twenty psychiatry and family medicine attending staff and residents were recruited to complete a 2.5-h study at a clinical interaction simulation centre with standardised patients. Each physician had the option of using the CDSS to inform their treatment choice in three 10-min clinical scenarios with standardised patients portraying mild, moderate and severe episodes of major depression. Feasibility and acceptability data were collected through self-report questionnaires, scenario observations, interviews and standardised patient feedback.

RESULTS

All 20 participants completed the study. Initial results indicate that the tool was acceptable to clinicians and feasible for use during clinical encounters. Clinicians indicated a willingness to use the tool in real clinical practice, a significant degree of trust in the system's predictions to assist with treatment selection, and reported that the tool helped increase patient understanding of and trust in treatment. The simulation environment allowed for the evaluation of the tool's impact on the physician-patient interaction.

CONCLUSIONS

The simulation centre allowed for direct observations of clinician use and impact of the tool on the clinician-patient interaction before clinical studies. It may therefore offer a useful and important environment in the early testing of new technological tools. The present results will inform further tool development and clinician training materials.

Patient Expectations and Experiences of Antidepressant Therapy for Major Depressive Disorder: A Qualitative Study

PURPOSE

This qualitative study explored patient perceptions of the most burdensome symptoms of major depressive disorder (MDD), the impact of symptoms on patients' daily lives, and patient expectations and experiences regarding the timing of onset of antidepressant pharmacotherapy.

PATIENTS AND METHODS

Data were collected through facilitated, patient focus-group sessions in the USA between May and June 2019. Participants were adults with confirmed MDD who reported a major depressive episode within the past 2 years, for which they had received pharmacologic treatment for ≥6 weeks. The semi-structured discussion focused on the key topics of bothersome symptoms of MDD, the impact of symptoms on quality of life, and the effects of antidepressant treatment. Interviews were audio-recorded; findings were summarized using a content-analysis approach.

RESULTS

Five focus-group sessions were undertaken, involving a total of 29 patients (each attended one session; mean age, 43.4 years; 72.4% female). Mean time since confirmed diagnosis of MDD was 13.1 years. The most commonly prescribed antidepressants received were bupropion (41.4% of participants), escitalopram (34.5%), and sertraline (34.5%). The most frequently reported bothersome MDD symptoms were fatigue (mentioned by 58.6% of participants), lack of motivation/loss of interest (51.7%), anxiety/panic (44.8%), sadness (41.4%), and lack of concentration/brain fog (41.4%). Socialization, family life, and work were the areas in which quality of life was most impacted. Participants expressed dissatisfaction with their antidepressant treatment. Fast symptom resolution was mentioned as a priority (defined as <1 week by 38.5% of participants and ≤1 month by 65.4%). Most participants had not experienced fast relief from their symptoms with current or previous antidepressant medications.

CONCLUSION

Results of this qualitative study suggest that fatigue, anhedonia, cognitive symptoms, and anxiety are some of the most bothersome symptoms for patients with MDD and highlight the importance of obtaining rapid relief from these symptoms in order to improve outcomes and patient satisfaction with antidepressant medication.

A Systematic Review of the Use of Telepsychiatry in Depression

Telepsychiatry, the use of televideo in psychiatric assessment and treatment, is utilized throughout Canada. Major depressive disorder (MDD) is common, with significant burdens of suffering and cost. This systematic review explores the literature on the use of televideo to diagnose and treat MDD, particularly acceptability and patient satisfaction, efficacy, and cost-effectiveness. A literature search was conducted for years 1946 to 2019. Study eligibility criteria included: MDD as the condition of interest, use of televideo technology, randomized controlled trials (RCTs), Adult (18 years or older) population, any clinical setting, and any healthcare professional providing care. The study must have included at least one of the following measures, satisfaction, efficacy, and cost-effectiveness. Fourteen studies were included. Satisfaction is equivalent to or significantly higher than face-to-face intervention. Both televideo and control groups found relief from depressive symptoms, with differences either statistically insignificant or in favour of televideo. Despite increased cost upfront for televideo due to the technology required, televideo would eventually be more cost-effective due to reducing travel expenses. Limitations include that there is little RCT data, and what exists often uses a collaborative treatment model. Many studies consisted solely of U.S. Veterans, and have limited generalizability. Further research needed to directly compare psychiatrist assessment over televideo versus in-person, and determine if particular patient subgroups benefit more from televideo or in-person intervention.Systematic review registration number: CRD42016048224.

Lower Health Literacy of Mania Than Depression Among Older People: A Random Survey of a Community Healthcare Service Center

Purpose: This study examines health literacy among older outpatients in two Community Healthcare Service Centers in Shanghai, China to facilitate the design of public education programs for the aged population on mood disorders (both depression and mania). Patients and Methods: A total of 173 outpatients aged 60 years or more with a chronic physical illness were randomly sampled. A health literacy questionnaire was used to assess participants' awareness of depression and mania. Participants were then asked to label two vignettes depicting depression and mania and to give their recommendations for how to seek help for those in the vignettes and how mood disorders should be managed. Results: In all, 86.1 and 36.4% of participants had heard of depression and mania, respectively, with the most common source of information being relatives and friends. Over half of the participants attributed the possible causes of mood disorders to psychological trauma, pressure or stress in daily life, taking things too hard, and personality problems. Almost two-thirds of participants correctly labeled the depression vignette, but only 26.6% correctly labeled the mania vignette. The most common methods recommended by the participants as being helpful for the individuals portrayed in the vignettes were "traveling" and help-seeking from a psychological therapist/counselor, a psychiatrist, or a close family member or friend. Conclusion: The older individuals attending community healthcare service settings in Shanghai have good depression literacy but relatively poor mania literacy. However, most participants had a positive attitude toward psychiatric treatment for mood disorders.

Comparison of Thyroid Hormone Levels Between Patients With Major Depressive Disorder and Healthy Individuals in China

Abnormal thyroid function in major depressive disorder (MDD) has been studied extensively, but the results still remain inconsistent. In China, few large-scale studies have investigated the differences in the levels of thyroid hormones between patients with MDD and healthy controls (HCs). In this retrospective, cross-sectional study, 535 MDD patients and 998 HCs were included. We compared the levels of thyroid hormones (FT3, FT4, and TSH) between the two groups, as well as investigated the distribution of levels of thyroid hormones within and outside normal ranges. The results showed that all the three hormones were significantly lower in MDD patients than in HCs, which was also true in different gender and age subgroups. The proportion of subjects with levels of all the three hormones outside the normal range in the MDD group was higher than that in the HC group (all p < 0.05). However, no significant difference was found in clinical/subclinical hyperthyroidism or hypothyroidism between the two groups (p > 0.05). Our study showed that the levels of thyroid hormones were lower in MDD patients, suggesting that there was an association between abnormal thyroid function and depression. The higher rate of thyroid dysfunction in MDD patients indicated the importance of regular monitoring of thyroid function.

Clinical traits of patients with major depressive disorder with comorbid borderline personality disorder based on propensity score matching

BACKGROUND

Major depressive disorder (MDD) with comorbid borderline personality disorder (BPD) makes the clinical symptoms of patients more complex and more difficult to treat, so more attention should be paid to the recognition of their clinical features. This study investigated the differences between patients with MDD with and without BPD in clinical traits.

METHODS

Propensity score matching was used to analyze the retrospective patients' data from August 2012 to September 2019. Altogether, 1381 patients with MDD were enrolled; 38 patients with MDD were matched to compare demographic data, and scores on the Hamilton Depression Scale, Hamilton Anxiety Scale (HAMA), Self-Rating Depression Scale (SDS), Modified Overt Aggression Scale (MOAS), and the frequency of nonsuicidal self-harm (NSSH).

RESULTS

Compared to patients with MDD without BPD, the age of onset of patients with MDD with comorbid BPD was significantly earlier (t = 3.25, p = .00). The scores of HAMA (t = -2.28, p = .03), SDS (t = 9.31, p = .00), MOAS (t = -13.67, p = .00), verbal aggression (t = -3.79, p = .00), aggression against objects (t = -2.84, p = .00), aggression against others (t = -6.70, p = .00), and aggression against self (t = -9.22, p = .00) were significantly higher in patients with MDD with comorbid BPD. Moreover, the frequency of NHSS in these patients was significantly higher (χ²  = 20.13, p = .00). MOAS was an independent influencing factor in these (odds ratio = 7.38, p = .00).

CONCLUSIONS

Patients with BPD showed early onset and increased complaints relative to symptoms, accompanied by obvious anxiety symptoms, impulsive behavior, and NSSH. Therefore, patients with MDD with impulsive behavior have comorbid BPD.

Impact of arthritis on the perceived need and use of mental healthcare among Canadians with mental disorders: nationally representative cross-sectional study

OBJECTIVE

To evaluate the association between having arthritis and the perceived need for mental healthcare and use of mental health support among individuals with mental disorders.

DESIGN

A cross-sectional analysis using data from Canadian Community Health Survey-Mental Health (2012).

SETTING

The survey was administered across Canada's 10 provinces using multistage cluster sampling.

PARTICIPANTS

The study sample consisted of individuals reporting depression, anxiety or bipolar disorder.

STUDY VARIABLES AND ANALYSIS

The explanatory variable was self-reported doctor-diagnosed arthritis, and outcomes were perceived need for mental healthcare and use of mental health support. We computed overall and gender-stratified multivariable binomial logistic regression models adjusted for age, gender, race/ethnicity, income and geographical region.

RESULTS

Among 1774 individuals with a mental disorder in the study sample, 436 (20.4%) reported having arthritis. Arthritis was associated with increased odds of having a perceived need for mental healthcare (adjusted OR (aOR) 1.71, 95% CI 1.06 to 2.77). In the gender-stratified models, this association was increased among men (aOR 2.69, 95% CI 1.32 to 5.49) but not women (aOR 1.48, 95% CI 0.78 to 2.82). Evaluation of the association between arthritis and use of mental health support resulted in an aOR of 1.50 (95% CI 0.89 to 2.51). Individuals with arthritis tended to use medications and professional services as opposed to non-professional support.

CONCLUSION

Comorbid arthritis among individuals with a mental disorder was associated with an increased perceived need for mental healthcare, especially in men, underscoring the importance of understanding the role of masculinity in health seeking. Assessing the mental health of patients with arthritis continues to be essential for clinical care.

Repetitive Transcranial Magnetic Stimulation With and Without Internet-Delivered Cognitive-Behavioral Therapy for the Treatment of Resistant Depression: Protocol for Patient-Centered Randomized Controlled Pilot Trial

BACKGROUND

Major depression is a severe, disabling, and potentially lethal clinical disorder. Only about half of patients respond to an initial course of antidepressant pharmacotherapy. At least 15% of all patients with major depressive disorder (MDD) remain refractory to any treatment intervention. By the time that a patient has experienced 3 definitive treatment failures, the likelihood of achieving remission with the fourth treatment option offered is below 10%. Repetitive transcranial magnetic stimulation (rTMS) is considered a treatment option for patients with MDD who are refractory to antidepressant treatment. It is not currently known if the addition of internet-delivered cognitive-behavioral therapy (iCBT) enhances patients' responses to rTMS treatments.

OBJECTIVE

This study will evaluate the initial comparative clinical effectiveness of rTMS with and without iCBT as an innovative patient-centered intervention for the treatment of participants diagnosed with treatment-resistant depression (TRD).

METHODS

This study is a prospective, two-arm randomized controlled trial. In total, 100 participants diagnosed with resistant depression at a psychiatric care clinic in Edmonton, Alberta, Canada, will be randomized to one of two conditions: (1) enrolment in rTMS sessions alone and (2) enrolment in the rTMS sessions plus iCBT. Participants in each group will complete evaluation measures (eg, recovery, general symptomatology, and functional outcomes) at baseline, 1 month, 3 months, and 6 months. The primary outcome measure will be the mean change to scores on the Hamilton Depression Rating Scale. Patient service utilization data and clinician-rated measures will also be used to gauge patient progress. Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses.

RESULTS

We expect the results of the study to be available in 24 months. We hypothesize that participants enrolled in the study who receive rTMS plus iCBT will achieve superior outcomes in comparison to participants who receive rTMS alone.

CONCLUSIONS

The concomitant application of psychotherapy with rTMS has not been investigated previously. We hope that this project will provide us with a concrete base of data to evaluate the practical application and efficacy of using a novel combination of these two treatment modalities (rTMS plus iCBT).

TRIAL REGISTRATION

ClinicalTrials.gov NCT0423965; https://clinicaltrials.gov/ct2/show/NCT04239651.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/18843.

Complementary and alternative medicine recommendations for depression: a systematic review and assessment of clinical practice guidelines

BACKGROUND

Up to 50% of individuals diagnosed with depression are known to use complementary and alternative medicine (CAM). The aim of this study was to identify the quantity and assess the quality of CAM recommendations in clinical practice guidelines for the treatment and/or management of depression in adults using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

METHODS

A systematic review was conducted to identify depression guidelines. MEDLINE, EMBASE and CINAHL were searched from 2008 to 2018. The Guidelines International Network and the National Center for Complementary and Integrative Health websites were also searched. Eligible guidelines published by non-profit agencies on treatment of depression for adults were assessed with the AGREE II instrument twice, once for the overall guideline and once for the CAM sections.

RESULTS

From 931 unique search results, 19 guidelines mentioned CAM, of which 16 made CAM recommendations. Scaled domain percentages from highest to lowest were as follows (overall, CAM section): clarity of presentation (87.0, 66.1%), scope and purpose (80.9, 77.6%), stakeholder involvement (62.0, 44.3%), editorial independence (61.6, 61.6%), rigour of development (58.0, 52.0%), and applicability (42.2, 25.4%). Quality varied within and across guidelines. Only 1 of 16 guidelines was recommended without modifications for both its overall and CAM sections by both appraisers.

CONCLUSIONS

There are multiple depression guidelines containing CAM recommendations available and there are a comprehensive set of CAM therapy options for depression. The quality of guidelines varied within and across guidelines and the quality of CAM recommendations was generally lower than the overall recommendations in the guidelines for all domains except editorial independence. Generally, characteristics of guidelines, including the year of publication and region of development varied across the guidelines irrespective of quality. Guidelines with higher AGREE II scores can serve as a guide to facilitate communication between patients and medical professionals regarding CAM use for depression, while guidelines with lower scores could be improved in future updates using the AGREE II instrument as a guide.

Reprint of: Psychosocial factors associated with pharmacists' antidepressant drug treatment monitoring

OBJECTIVE

Patients undergoing antidepressant drug treatment (ADT) may face challenges regarding its adverse effects, adherence, and efficacy. Community pharmacists are well positioned to manage ADT-related problems. Little is known about the factors influencing pharmacists' ADT monitoring. This study aimed to identify the psychosocial factors associated with pharmacists' intention to perform systematic ADT monitoring and report on this monitoring.

DESIGN

Cross-sectional study based on the Theory of Planned Behavior (TPB).

SETTING AND PARTICIPANTS

Community pharmacists in the province of Quebec, Canada.

OUTCOME MEASURES

Pharmacists completed a questionnaire on their performance of ADT monitoring, TPB constructs (intention; attitude; subjective norm; perceived behavioral control; and attitudinal, normative, and control beliefs), and professional identity. Systematic ADT monitoring was defined as pharmacists' reporting 4 or more consultations with each patient during the first year of ADT to address adverse effects, adherence, and efficacy. Hierarchical linear regression models were used to identify the factors associated with the intention and reporting of systematic ADT monitoring and Poisson working models to identify the beliefs associated with intention.

RESULTS

A total of 1609 pharmacists completed the questionnaire (participation = 29.6%). Systematic ADT monitoring was not widely reported (mean score = 2.0 out of 5.0), and intention was moderate (mean = 3.2). Pharmacists' intention was the sole psychosocial factor associated with reporting systematic ADT monitoring (P < 0.0001; R² = 0.370). All TPB constructs and professional identity were associated with intention (P < 0.0001; R² = 0.611). Perceived behavioral control had the strongest association.

CONCLUSION

Interventions to promote systematic ADT monitoring should focus on developing a strong intention among pharmacists, which could, in turn, influence their practice. To influence intention, priority should be given to ensuring that pharmacists feel capable of performing this monitoring. The main barriers to overcome were the presence of only 1 pharmacist at work and limited time. Other factors identified offer complementary intervention targets.

Development and implementation of guidelines for the management of depression: a systematic review

Objective

To evaluate the development and implementation of clinical practice guidelines for the management of depression globally.

Methods

We conducted a systematic review of existing guidelines for the management of depression in adults with major depressive or bipolar disorder. For each identified guideline, we assessed compliance with measures of guideline development quality (such as transparency in guideline development processes and funding, multidisciplinary author group composition, systematic review of comparative efficacy research) and implementation (such as quality indicators). We compared guidelines from low- and middle-income countries with those from high-income countries.

Findings

We identified 82 national and 13 international clinical practice guidelines from 83 countries in 27 languages. Guideline development processes and funding sources were explicitly specified in a smaller proportion of guidelines from low- and middle-income countries (8/29; 28%) relative to high-income countries (35/58; 60%). Fewer guidelines (2/29; 7%) from low- and middle-income countries, relative to high-income countries (22/58; 38%), were authored by a multidisciplinary development group. A systematic review of comparative effectiveness was conducted in 31% (9/29) of low- and middle-income country guidelines versus 71% (41/58) of high-income country guidelines. Only 10% (3/29) of low- and middle-income country and 19% (11/58) of high-income country guidelines described plans to assess quality indicators or recommendation adherence.

Conclusion

Globally, guideline implementation is inadequately planned, reported and measured. Narrowing disparities in the development and implementation of guidelines in low- and middle-income countries is a priority. Future guidelines should present strategies to implement recommendations and measure feasibility, cost–effectiveness and impact on health outcomes.

Why people choose to participate in psychotherapy for depression: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Medication does not always resolve a serious mood episode, and there is evidence that it needs to be combined with an evidence-based psychotherapy to promote symptomatic and functional recovery. There is little known about what people with serious mood disorders want from mental health services to manage their mood. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Participants in this study wanted a framework other than the medical model for understanding and managing their mood. Their motivation to commence psychotherapy was based on a sense of having hit rock bottom and a need for understanding what was happening in order to better manage their mood. ABSTRACT: Introduction There is little known about the motivations for people to participate in psychotherapy for depression. Aim To explore why people, with a diagnosis of major depressive episode, chose to take part in a psychotherapy study and what they expected it to involve. Method This was a qualitative study of participants' motivations and understandings of psychotherapy for depression. Data were collected using semi-structured interviews and analysed using thematic analysis. Findings Eight females and eight males with an age range from 21 years to 55 years were recruited. Three themes were identified that described why participants chose to participate in psychotherapy: medication was not enough, a turning point and making sense of experience. The participants chose to participate in psychotherapy after finding that medication was insufficient and this combined with a sense of crisis motivated them to engage in psychotherapy in order to learn to manage their mood differently. Discussion The participants recognized that they wanted a framework other than a medical model with its reliance on medication, in order to make sense of their experiences and develop new self-management strategies. Implications for Practice Our study suggests that some people experiencing a serious mood disorder access psychotherapy after "hitting rock bottom" and finding insufficient help from medications. Mental health nurses need to be aware people do not always want a medical model approach to treatment of serious mood disorders and they need to provide the opportunity of engaging in a psychotherapeutic framework in order to better understand and manage their mood.

Collaborating with individuals with lived experience to adapt CANMAT clinical depression guidelines into a patient treatment guide: The CHOICE-D co-design process

Effective treatment of depression involves collaboration with informed patients and families and appropriate knowledge sharing. We describe here our experience, as a case example, of a collaboration to "translate" a clinical guideline designed for practitioners into an accessible, plainlanguage version that patients and families can use during the care process, both to provide basic educational information and to foster informed discussions with their treatment providers. Content experts in knowledge translation, patient advocacy, patient-oriented research, and psychiatry guided overall project design. Our first step was to identify lived experience writers to join in the codesign and co-writing of the "CHOICE-D Patient and Family Guide to Depression Treatment." A national call for writers attracted 62 applicants, from whom eight individuals with lived experience of depression and writing experience were selected. Individuals subsequently attended a welcoming teleconference, followed by a 1-day workshop designed to provide (a) a detailed overview of the clinician guideline, (b) an opportunity to select what should be included in the Guide, and (c) key principles of knowledge translation/lay writing. Both from the workshop and subsequently through the codesign process, lived experience writers recommended that the Guide address symptoms, effects of illness course on treatment, first-line treatments, safety/side effects, and treatment misconceptions. To promote patient autonomy, question scripts (how and what to ask your treatment provider), self-triaging resources, and treatment selection aids were suggested. Stylistic considerations included use of simple yet hopeful language, brevity, white space, key terms glossary, and graphics. Several strategies were particularly useful to optimize writer engagement in the codesign process: a pre-workshop conference call and circulation of project resources, an in-person workshop to increase content knowledge, structured discussion with co-writers and project leads to develop ideas, and practical training exercises with the provision of feedback. Both during and at the end of the project, writers provided additional recommendations for improving the process, including more in-person meetings, distribution of step-by-step instructions on the writing task, and a key terms glossary of technical terms to support their role. In conclusion, we describe a process with practical tips and reflective feedback on important considerations for engaging persons with lived experience as leaders in the codesign and writing process of lay treatment guidelines. These methods may serve as a model for similar projects in other areas of healthcare.

Esketamine: new hope for the treatment of treatment-resistant depression? A narrative review

This narrative review aims to provide an overview of the current literature on the pharmacology, safety, efficacy and tolerability of intranasal esketamine, the S-enantiomer of ketamine, for the treatment of treatment-resistant depression (TRD). A literature search using Medline, Embase, PsycINFO and Cochrane Central was conducted (January 2000 to July 2019). Product information and www.clinicaltrials.gov were also reviewed. The literature search was limited to human studies published in English. Phase I, II, and III studies of intranasal esketamine for TRD were reviewed. About a third of patients with major depressive disorder fail to achieve remission despite treatment with multiple antidepressants. This article examines the trials that led to the approval of esketamine in the United States, as well as other recent studies of esketamine for TRD. The findings from limited phase III trials illustrate that intranasal esketamine is effective and safe in reducing depressive symptoms and achieving clinical response in patients with TRD. The optimum duration and frequency of use are not fully understood. Although the nasal spray is a convenient dosage form, its use in practice may be limited by cost and administrative regulation. While it may prove beneficial to many patients who suffer from TRD, further long-term data are required, along with comparative trials with the R-isomer (arketamine). In the interim, care and monitoring should be exercised in its use in clinical practice.

Environmental enrichment and its influence on rodent offspring and maternal behaviours, a scoping style review of indices of depression and anxiety

Environmental enrichment is a widely used experimental manipulation that consistently shows measurable effects on rodent behaviour across the lifespan. This scoping review assesses and thematically summarizes the literature of the past decade concerning the effects of environmental enrichment applied during sensitive developmental periods in rodent mothers and offspring. Maternal behaviours as well as maternal and offspring anxiety- and depressive-like behaviours are considered. Relevant terms were searched across five databases (Embase, MEDLINE, PsycINFO, PubMed, Web of Science) and articles were screened with inclusion and exclusion criteria. The remaining articles were thematically analysed. Our results suggest that a greater number of articles reviewed the impacts of environmental enrichment on offspring anxiety-like behaviour (n = 23) rather than on depressive-like behaviour (n = 11) or maternal caregiving behaviour (n = 12). Maternal anxiety- (n = 4) or depressive-like (n = 2) behaviours are not often evaluated for in enrichment studies. The main behavioural tests of anxiety that were reviewed include the elevated plus-maze, the open field test, and the light-dark box whereas those for depression included the forced swim test and the sucrose preference test. Our results yielded mixed findings and significant variation in behavioural responses across all tests. In mothers, trends of increased maternal care behaviours and decreased maternal depressive-like behaviours in enriched mothers were appreciated. Enrichment during the gestational period was identified as pivotal to creating behavioural change in mother subjects. In enriched offspring rodents, a trend towards decreased anxiety-like behaviours was observed most often. Potential confounds inherent in enrichment paradigms and relevant theories of enrichment and their relation to rodent behavioural tests are discussed.

Canadian economic impact of improved workplace productivity in patients with major depressive disorder treated with vortioxetine

OBJECTIVE

The AtWoRC study is an interventional, open-label Canadian study that demonstrated significant improvements in cognitive function and workplace productivity in patients with major depressive disorder (MDD) treated with vortioxetine for a current major depressive episode. The objective of the present analysis was to assess the Canadian economic impact of improved workplace productivity based on the AtWoRC study results.

METHODS

The economic impact of improved productivity in patients with MDD treated with vortioxetine was assessed over a 52-week period considering productivity loss due to absenteeism and presenteeism using the standard human capital approach and an employer's perspective. Absenteeism was measured with the Work Productivity and Activity Impairment questionnaire; and presenteeism with the Work Limitation Questionnaire. Productivity gains following treatment initiation with vortioxetine were estimated using the difference from baseline.

RESULTS

In the AtWoRC study, patients at baseline reportedly missed, in the past 7 days, an average of 8.1 h due to absenteeism and 3.0 h due to presenteeism. Following 52 weeks of treatment with vortioxetine, patients reportedly missed an average of 4.9 h due to absenteeism and 2.0 h due to presenteeism. This improved workplace productivity translated into savings of C$110.64 for 1 week of work following 52 weeks of treatment. The cumulative 52-week economic impact showed potential savings of C$4,550 when factoring in the cost of therapy.

CONCLUSION

This study suggested that workplace productivity gain due to an improvement in symptoms of MDD following treatment with vortioxetine will lead to substantial cost savings for the Canadian economy.

Antidepressant-resistant depression is characterized by reduced short- and long-interval cortical inhibition

BACKGROUND

Major depressive disorder (MDD) is highly heterogeneous and can be classified as treatment-resistant depression (TRD) or antidepressant-responsive depression (non-TRD) based on patients' responses to antidepressant treatment. Methods for distinguishing between TRD and non-TRD are critical clinical concerns. Deficits of cortical inhibition (CI) have been reported to play an influential role in the pathophysiology of MDD. Whether TRD patients' CI is more impaired than that of non-TRD patients remains unclear.

METHODS

Paired-pulse transcranial magnetic stimulation (ppTMS) was used to measure cortical inhibitory function including GABAA- and GABAB-receptor-related CI and cortical excitatory function including glutamate-receptor-related intracortical facilitation (ICF). We recruited 36 healthy controls (HC) and 36 patients with MDD (non-TRD, n = 16; TRD, n = 20). All participants received evaluations for depression severity and ppTMS examinations. Non-TRD patients received an additional ppTMS examination after 3 months of treatment with the SSRI escitalopram.

RESULTS

Patients with TRD exhibited reduced short-interval intracortical inhibition (SICI) and long-interval intracortical inhibition (LICI), as shown by abnormally higher estimates, than those with non-TRD or HC (F = 11.030, p < 0.001; F = 10.309, p < 0.001, respectively). After an adequate trial of escitalopram treatment, the LICI of non-TRD reduced significantly (t = - 3.628, p < 0.001), whereas the ICF remained lower than that of HC and showed no difference from pretreatment non-TRD.

CONCLUSIONS

TRD was characterized by relatively reduced CI, including both GABAA- and GABAB-receptor-mediated neurons while non-TRD preserved partial CI. In non-TRD, SSRIs may mainly modulate GABAB-receptor-related LICI. Our findings revealed distinguishable features of CI in antidepressant-resistant and responsive major depression.

Predictors of functional response and remission with desvenlafaxine 50 mg and 100 mg: a pooled analysis of randomized, placebo-controlled studies in patients with major depressive disorder

OBJECTIVE

The value of early functional improvement at week 2 for predicting subsequent functional outcomes at week 8 was assessed in a pooled analysis of patients with major depressive disorder (MDD) treated with desvenlafaxine (50 or 100 mg/d) or placebo.

METHODS

Data were pooled from eight double-blind, placebo-controlled studies of desvenlafaxine 50 mg/d or 100 mg/d for the treatment of MDD. Optimal week-2 improvement thresholds in Sheehan Disability Scale (SDS) score, which best predicted week-8 treatment success, were determined using receiver operating characteristic (ROC) analysis. Four definitions of treatment success were established: (1) functional response, (2) functional/depression response, (3) functional remission, and (4) functional/depression remission. Odds ratios (ORs) of early improvement for prediction (based on thresholds determined in the ROC analysis) of week-8 treatment success were computed using logistic regression models.

RESULTS

Functional early improvement thresholds of 17%-32% were predictive of week-8 treatment success across treatment groups and definitions of treatment success. Optimal thresholds were higher for more stringent definitions. Negative predictive value exceeded positive predictive value, indicating that failure to achieve early functional improvement was more informative about later treatment success than was the achievement of early functional improvement. Early change in SDS was a highly significant predictor of functional response/remission (ORs, 4.981-8.737; all p < 0.0001); the interaction between treatment and early functional improvement was not significant.

CONCLUSION

Early improvement in SDS total score was predictive of functional outcomes for patients treated with desvenlafaxine 50 mg, desvenlafaxine 100 mg, or placebo.

Prospective testing of a neurophysiologic biomarker for treatment decisions in major depressive disorder: The PRISE-MD trial

Management of Major Depressive Disorder (MDD) might be improved by a biomarker to predict whether a selected medication is likely to lead to remission. We previously reported on a quantitative electroencephalogram-based biomarker, the Antidepressant Treatment Response (ATR) index, that integrated recordings at baseline and after one week of treatment. The present study prospectively tested whether treatment directed by the biomarker increased the likelihood of remission; we hypothesized that continued treatment with a drug predicted to lead to remission (i.e., high ATR values) would be associated with better outcomes than if the drug was predicted not to lead to remission (i.e., low ATR values). We enrolled 180 adult outpatients with unipolar MDD from the community. After one week of escitalopram treatment to determine the biomarker, stratified randomization (high vs. low ATR) was used to assign subjects to either continued escitalopram or a switch to bupropion as a blinded control condition, for seven additional weeks. For the 73 evaluable subjects assigned to continued escitalopram treatment, the remission rate was significantly higher for those in whom ATR had predicted remission versus non-remission (60.4% vs. 30.0%, respectively, p = 0.01). Accuracy was enhanced by combining 1-week depressive symptom change with ATR (68.6% vs 28.9%). This prospective validation study supports further development of the ATR biomarker, alone or together with early symptom change, to improve care by identifying individuals unlikely to remit with their current treatment, and support the decision to change treatment after one week rather than after failing a full, prolonged course of medication.

Successfully treated patients with vortioxetine versus venlafaxine: a simplified cost-effectiveness analysis based on a head-to-head study in Asian patients with major depressive disorder

Objective: To compare the rates of successfully treated patients (STPs) with vortioxetine versus venlafaxine in major depressive disorder (MDD), using dual endpoints that combine improvement of mood symptoms with optimal tolerability or functional remission, and conduct a simplified cost-effectiveness analysis.Methods: The 8-week SOLUTION study (NCT01571453) assessed the efficacy and safety of vortioxetine (10 mg/day) versus venlafaxine XR (150 mg/day) in adult Asian patients with MDD. Rates were calculated post-hoc of STP Mood and Tolerability (≥50% reduction from baseline in Montgomery-Åsberg Depression Rating Scale [MADRS] total score and no treatment-emergent adverse events) and STP Mood and Functioning (≥50% reduction from baseline in MADRS total score and Sheehan Disability Scale total score ≤6). The incremental costs per STP were assessed using the 2018 pharmacy purchase prices for branded vortioxetine/branded venlafaxine in China as the base case.Results: STP Mood and Tolerability rates were 28.9% for vortioxetine and 19.9% for venlafaxine (p = .028); the corresponding STP Mood and Functioning rates were 28.0% and 23.5% (p = .281). Drug costs for the 8-week treatment period were CN¥1954 for vortioxetine and CN¥700 for venlafaxine. The incremental cost per STP for vortioxetine versus venlafaxine was CN¥13,938 for Mood and Tolerability and CN¥27,876 for Mood and Functioning.Conclusions: Higher rates of dual treatment success were seen with vortioxetine versus venlafaxine. Although vortioxetine was not dominant in the base case, the incremental cost per STP for vortioxetine versus venlafaxine were overall within acceptable ranges. These results support the benefits previously reported with vortioxetine versus other antidepressants in broad efficacy, tolerability profile and cost-effectiveness.

Effect of venlafaxine dosage, valproic acid concentration, sex, and age on steady state dose-corrected concentrations of venlafaxine and O-desmethylvenlafaxine: A retrospective analysis of therapeutic drug monitoring data in a Chinese population

PURPOSE

This study aimed to investigate the influence of diagnosis, body weight, sex, age, smoking, formulations, and concomitant drugs on steady-state dose-corrected serum concentrations (C/D) of venlafaxine (VEN) and O-desmethylvenlafaxine (ODV).

METHODS

A retrospective analysis of therapeutic drug monitoring (TDM) was carried out. Patients' demographic data, therapeutic regimens, and concentrations were collected.

RESULTS

We included 91 verified samples from 80 patients. Females had by average 13% smaller body weight, 50% higher C/D of VEN, and VEN + ODV and 25% smaller ODV/VEN than males. Patients >60 years had by average 33-59% higher C/D levels of ODV and VEN + ODV than younger patients. The concomitant use of valproic acid caused an average 51% higher C/D of ODV and a 2.2-fold larger ODV/VEN, while clozapine was related with 40% smaller ratio of ODV/VEN and 38% lower C/D levels of ODV. Positive correlations were detected between valproic acid concentrations and the C/D of VEN and VEN + ODV. In a multiple linear regression analysis, variance in the C/D of VEN + ODV was partly attributed to the daily dose of VEN, sex, age and valproic acid concentration.

CONCLUSION

Our results suggested daily dose of VEN, sex, age, and valproic acid as indicators for the C/D of VEN + ODV in Chinese patients. TDM as a valuable tool was suggested in elderly female patients and patients receiving polypharmacy.

Mefenamic acid can attenuate depressive symptoms by suppressing microglia activation induced upon chronic stress

BACKGROUND

Depression is the most debilitating neuropsychiatric disorder, and psychosocial stressors are major risk factors for the onset of depression. Depression is closely associated with chronic inflammation and microglia are the principal mediators of inflammation in the central nervous system (CNS). Mefenamic acid (MA) and celecoxib are nonselective and selective inhibitors of cyclooxygenase (COX), respectively. COX is a key enzyme in mediating inflammatory response in microglia. In this study, we examine the effects of inhibiting COX by MA on depressive-like behaviors and microglia activation in the hippocampus.

METHODS

We evaluate the effect of MA on chronic mild stress (CMS) induced depressive-like behavior by sucrose preference and forced swimming tests. Effect of MA on microglia activation in dentate gyrus (DG) of hippocampus was examined by immunohistochemistry. In vitro experiments including western blotting and phagocytosis assay were used to investigate the effect of MA on microglia activation.

RESULTS

Behavioral assays reveal MA and celecoxib ameliorate CMS-induced depressive-like behavior. Compared to the stressed mice, the number of activated/phagocytic microglia (Iba1⁺/CD68⁺) in DG of hippocampus significantly decreases in stressed mice treated with MA or celecoxib. MA and celecoxib play a role in inhibiting microglia activation by inhibiting of ERK1/2 and P38 MAPK activation and iNOS expression. MA or celecoxib also reduce the high phagocytic activity of activated microglia.

CONCLUSION

MA inhibits microglia activation/phagocytosis induced upon chronic stress in the hippocampus, which might result in the improvement of depressive symptoms.

Concordance between clinician-rated and patient reported outcome measures of depressive symptoms in treatment resistant depression

BACKGROUND

Calls to implement measurement-based care (MBC) in psychiatry are increasing. A recent Cochrane meta-analysis concluded that there is insufficient evidence that routine application of patient reported outcomes (PROs) improves treatment outcomes for common psychiatric disorders. There is a particular paucity of this information in patients with treatment resistant depression (TRD).

METHODS

A TRD sample (n = 302) and a treatment-naïve sample with major depression (n = 344) were assessed for the level of agreement in depression severity between two PROs (the Beck Depression Inventory, BDI, and the Quick Inventory of Depressive Symptomatology Self-report, QIDS-SR) and two Clinician Rated (CRs) measures (Hamilton Depression Rating Scale, HDRS, and the Montgomery-Asberg Depression Rating Scale, MADRS).

RESULTS

Correlations between CR and PRO total scores in the TRD sample ranged from 0.57 (HDRS-QIDS-SR) to 0.68 (MADRS-BDI), reflecting a moderate-to-strong relationship between assessment tools. Correlations in the treatment naïve sample were non-significantly lower for most comparisons, ranging from 0.51 (HDRS-QIDS-SR) to 0.64 (MADRS-BDI). Few predictors of discordance between CRs and PROs were identified, though chronicity of the current episode in treatment-naïve patients was associated with greater agreement.

LIMITATIONS

Inter-rater reliability of the clinician interviews was conducted separately within the two studies so we could not determine the reliability between the two groups of raters used in the studies.

CONCLUSION

Findings generally supported acceptably high levels of agreement between patient and clinician ratings of baseline depression severity. More work is needed to determine the extent to which PROs can improve outcomes in MBC for depression and, more specifically, TRD.

Psychosocial factors associated with pharmacists' antidepressant drug treatment monitoring

OBJECTIVE

Patients undergoing antidepressant drug treatment (ADT) may face challenges regarding its adverse effects, adherence, and efficacy. Community pharmacists are well positioned to manage ADT-related problems. Little is known about the factors influencing pharmacists' ADT monitoring. This study aimed to identify the psychosocial factors associated with pharmacists' intention to perform systematic ADT monitoring and report on this monitoring.

DESIGN

Cross-sectional study based on the Theory of Planned Behavior (TPB).

SETTING AND PARTICIPANTS

Community pharmacists in the province of Quebec, Canada.

OUTCOME MEASURES

Pharmacists completed a questionnaire on their performance of ADT monitoring, TPB constructs (intention; attitude; subjective norm; perceived behavioral control; and attitudinal, normative, and control beliefs), and professional identity. Systematic ADT monitoring was defined as pharmacists' reporting 4 or more consultations with each patient during the first year of ADT to address adverse effects, adherence, and efficacy. Hierarchical linear regression models were used to identify the factors associated with the intention and reporting of systematic ADT monitoring and Poisson working models to identify the beliefs associated with intention.

RESULTS

A total of 1609 pharmacists completed the questionnaire (participation = 29.6%). Systematic ADT monitoring was not widely reported (mean score = 2.0 out of 5.0), and intention was moderate (mean = 3.2). Pharmacists' intention was the sole psychosocial factor associated with reporting systematic ADT monitoring (P < 0.0001; R² = 0.370). All TPB constructs and professional identity were associated with intention (P < 0.0001; R² = 0.611). Perceived behavioral control had the strongest association.

CONCLUSION

Interventions to promote systematic ADT monitoring should focus on developing a strong intention among pharmacists, which could, in turn, influence their practice. To influence intention, priority should be given to ensuring that pharmacists feel capable of performing this monitoring. The main barriers to overcome were the presence of only 1 pharmacist at work and limited time. Other factors identified offer complementary intervention targets.

Prevalence of depressive, bipolar and adjustment disorders, in Quebec, Canada

BACKGROUND

The prevalence of mood disorders was estimated at 5.4% according to the latest Canadian survey. It has been suggested to use administrative data and self-reported data to optimize the estimation for mental health care in the population. Using administrative data, algorithms (combination of codes from the International Classification of Diseases) had been previously developed to identify the population with mood and anxiety disorders. However, the specific prevalence of each component of mood disorders (depressive, bipolar and adjustment disorders) are still unknown in Quebec, Canada.

OBJECTIVE

To 1) identify the population diagnosed respectively with depressive, bipolar and adjustment disorders in administrative data, and 2) provide annual prevalence estimates of each component.

METHOD

Data were extracted from the Quebec Integrated Chronic Disease Surveillance System and the entire population of Quebec (2000-2017) was included in this study (8.3 million; 2017). The prevalence of depressive, bipolar and adjustment disorders were estimated using specific algorithms.

RESULTS

The annual prevalence of depressive disorders was 3.7% in 2000-2001; it decreased to 2.8% in 2016-2017. In comparison, the prevalence of bipolar disorders was 0.8% in 2000-2001, decreasing to 0.6% in 2016-2017, and the prevalence of adjustment disorders was 1.3% in 2000-2001 and increased to 1.6% in 2016-2017.

CONCLUSION

Using specific algorithms, we observed that the trend of adjustment disorders is increasing while trends of depressive and bipolar disorders are decreasing. Further studies should assess if the related burden of care respectively follows the same trends as policy makers' allocations of resources may need to be adapted.

Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders.

METHODS

We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings.

FINDINGS

We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs.

LIMITATIONS

Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed.

CONCLUSION

Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient- and family-centeredness of collaborative care.

Improvements in Workplace Productivity in Working Patients With Major Depressive Disorder: Results From the AtWoRC Study

OBJECTIVE

To assess changes in workplace productivity and functioning in an open-label study in working patients receiving vortioxetine (10 to 20 mg/d) for major depressive disorder (MDD).

METHODS

Associations between items in the Work Limitations Questionnaire (WLQ), the Sheehan Disability Scale (SDS), and the Work Productivity and Activity Impairment (WPAI) questionnaire were assessed at 12 and 52 weeks by Pearson correlation coefficients.

RESULTS

Significant improvements were observed across all domains of workplace productivity and functioning after 12 and 52 weeks' vortioxetine treatment. Strong correlations were seen between improvements in WLQ mental domains and WPAI presenteeism and SDS work/school items. Presenteeism showed stronger correlations with other workplace productivity measures than absenteeism.

CONCLUSIONS

Presenteeism and absenteeism impact productivity in working patients with MDD. Vortioxetine confers long-term benefits across all workplace functioning domains.

Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ?

This analysis was undertaken to examine the relationship between different symptoms of major depressive disorder (MDD) and psychosocial functioning from the perspectives of patients and healthcare providers (HCPs) across the different phases of the disease (acute, post-acute, and remission). Data regarding symptoms of MDD and psychosocial functioning, assessed by an adapted version of the Functioning Assessment Short Test (FAST) scale, were elicited via an online survey from 2,008 patients diagnosed with MDD (based on their personal experience of the disease) and 3,138 patients observed by 1,046 HCPs (based on individual patient records). Correlations between patient-reported and HCP-reported MDD symptoms and impairment of psychosocial functioning were assessed by multivariate regression analysis. The population comprised 1,946 patient respondents and 3,042 HCP-reported patients. Patients reported experiencing a wider range of symptoms and greater impairment of functioning than reported by HCPs across all phases of the disease. At the domain level, only cognitive symptoms were found to be significantly associated with functioning during the acute phase from the perspective of patients, while from the HCPs' perspective both mood and cognitive symptoms significantly impacted functioning in this phase. Significant associations were seen between mood, physical, and cognitive symptom domains and functioning in both cohorts during the post-acute and remission phases. Differences in associations between individual MDD symptoms and functioning were also observed between the two cohorts across all disease phases; in particular, HCPs found that more physical symptoms impacted functioning during remission than did patients. In summary, the results suggest that perceptions of MDD symptoms and the associations between these symptoms and functioning differ significantly between patients and HCPs across all phases of the disease. These findings further highlight the need for improved communication between patients and HCPs in order to set appropriate treatment goals and promote symptomatic and functional recovery in MDD.

Safety and Tolerability of Both Arm Ischemic Conditioning in Patients With Major Depression: A Proof of Concept Study

PURPOSE

A substantial proportion of patients with major depressive disorder (MDD) does not respond or cannot tolerate to currently available treatments. This study was to assess the safety and tolerability of Remote Limb Ischemic Preconditioning (RLIPC) as an adjunctive therapy in patients with MDD.

PATIENTS AND METHODS

Enrolled patients underwent RLIPC, five cycles of simultaneous bilateral arm ischemia, 5 min and followed by reperfusion of each cycle, and once daily for eight consecutive weeks. Depression and anxiety severity, and quality of life were assessed every 2 weeks. Descriptive analysis was used for safety and tolerability data.

RESULTS

Thirty-seven participants completed at least one RLIPC. Twenty-four of them (64.9%) completed the study. Twelve patients prematurely discontinued the study due to poor adherence, and one due to a mild side effect. The changes in HRSD-17, GAD-7 and QOL-6 total scores from baseline to the endpoint were significant from the end of second week treatment onwards. The responder and remission rates were 59.46% (22/37) and 54.05% (20/37) at the endpoint, respectively.

CONCLUSION

RLIPC was safe and well tolerated, and may be effective in reducing depressive symptoms in patients with MDD. Large studies are warranted to test its efficacy and safety as monotherapy or adjunctive therapy in the treatment of MDD.

Definition and Identification of Patients with Treatment-Resistant Depression in Real-World Clinical Practice Settings Across Asia

PURPOSE

An Asia-Pacific expert consensus defined treatment-resistant depression (TRD) as failure of ≥2 antidepressants given at adequate doses for 6-8 weeks during a major depressive episode. A survey examined how TRD was being diagnosed in real-world practices across Asia. An expert panel then interpreted the results and provided practical recommendations.

METHODS

Between March and July 2018, 246 clinicians from Hong Kong, Japan, Mainland China, South Korea, and Taiwan were surveyed on how they identified TRD patients according to their own definitions.

RESULTS

Most physicians described antidepressant failure as "no response" (79%) or "inadequate response" (82%); fewer chose "failure to achieve remission" (45%). About 40% did not routinely use clinical tools to assess response. Around 52% defined adequate dose target as achieving the label's upper dose limit. About 58% would treat for 4-8 weeks before determining antidepressant failure. Most (76%) required the ≥2 qualifying antidepressant failures to be from different classes. Approximately 60% considered antidepressant failure(s) from previous depressive episode(s) when diagnosing TRD.

CONCLUSION

Considering the survey results, antidepressant failure can be defined as a failure to achieve remission, or more practically as <50% improvement in depressive symptoms or inability to return to work/study, and confirmed with a clinical tool. TRD diagnosis also requires ≥2 qualifying antidepressant failures within the same depressive episode; from the same or different classes; and achieving at least the minimum effective antidepressant dose for 6-8 weeks.

Research on the Development of Theme Trends and Changes of Knowledge Structures of Drug Therapy Studies on Major Depressive Disorder Since the 21st Century: A Bibliometric Analysis

BACKGROUND

Antidepressant treatment is one of the most effective ways of relieving or curing depressive symptoms in patients with major depressive disorder (MDD). Although many studies have explored the efficacy, tolerability, adverse reactions, and functional mechanism of the disease, there has been no systematic evaluation of the relevant results in this field.

AIM

This paper aims to analyze the theme trends and knowledge structure of drug therapy studies on MDD since the 21^st century by employing bibliometric analysis.

METHODS

Literature published in PubMed and related to drug therapy studies on MDD were retrieved between 2001 and 2018 in 6-year increments. After extracting major Medical Subject Headings (MeSH) terms/MeSH subheadings, bi-clustering analysis, social network analysis, and strategic diagrams were employed to complete bibliometric analysis.

RESULTS

Overall, 1,577, 2,680, 2,848 relevant research articles were retrieved for the periods during 2001-2006, 2007-2012, and 2013-2018, respectively. In line with strategic diagrams, the main undeveloped and peripheral theme clusters during 2001-2006 were functional mechanisms of antidepressants in pathophysiology, neuroendocrinology and neural biochemistry. These themes were replaced during 2007-2012 by clinical efficacy and influencing factors of antidepressants with or without psychotherapy, mechanisms of adverse reactions of antidepressants, and predictive studies of clinical therapeutic effects of antidepressants based on brain imaging. During 2013-2018 application and evaluation of new antidepressant agents, early identification and prevention of suicide of patients with MDD, as well as genetic- or bio-markers affecting the response and efficacy of antidepressants were the primary themes. Based on social network analyses, emerging hotspots, such as antidepressive agents, second-generation/adverse effects, depressive disorder, major/metabolism, psychotherapy/methods, and brain/drug effects could be identified during 2007-2012 and 2013-2018.

CONCLUSIONS

These undeveloped theme clusters and emerging hotspots can be helpful for researchers to clarify the current status of their respective fields and future trends, and to generate novel ideas that may launch new research directions.

Management of Treatment-Resistant Depression in Real-World Clinical Practice Settings Across Asia

PURPOSE

Consensus is lacking on the management of treatment-resistant depression (TRD), resulting in significant variations on how TRD patients are being managed in real-world practice. A survey explored how clinicians managed TRD across Asia, followed by an expert panel that interpreted the survey results and provided recommendations on how TRD could be managed in real-world clinical settings.

METHODS

Between March and July 2018, 246 clinicians from Hong Kong, Japan, Mainland China, South Korea, and Taiwan completed a survey related to their treatment approaches for TRD.

RESULTS

The survey showed physicians using more polytherapy (71%) compared to maintaining patients on monotherapy (29%). The most commonly (23%) administered polytherapy involved antidepressant augmentation with antipsychotics that 19% of physicians also indicated as their most important approach for managing TRD. The highest number of physicians (34%) ranked switching to another class of antidepressants as their most important approach, while 16% and 9% chose antidepressant combinations and electroconvulsive therapy (ECT), respectively.

CONCLUSION

Taking into account the survey results, the expert panel made general recommendations on the management of TRD. TRD partial-responders to antidepressants should be considered for augmentation with second-generation antipsychotics. For non-responders, switching to another class of antidepressants ought to be considered. TRD patients achieving remission with acute treatment should consider continuing their antidepressants for at least another 6 months to prevent relapse. ECT is a treatment consideration for patients with severe depression or persistent symptoms despite multiple adequate trials of antidepressants. Physicians should also consider the response, tolerability and adherence to the current and previous antidepressants, the severity of symptoms, comorbidities, concomitant medications, preferences, and cost when choosing a TRD treatment approach for each individual patient.

Anxiety and depression symptoms in adult males in Atlantic Canada with or without a lifetime history of prostate cancer

OBJECTIVE

Prostate cancer (PCa) is the most prevalent form of cancer among men and has one of the most favorable survival rates among all cancers. Here we examine the association between depression and anxiety symptoms in a population-based sample of men.

METHODS

A cross-sectional analysis was conducted on a subsample of 6 585 male participants aged 49-69 from 2009 to 2015 survey cycle of the Atlantic PATH. Mild, moderate or severe depression or anxiety indicators were primary outcomes and were assessed using the Generalized Anxiety Disorder (GAD-7) scale and the Patient Health Questionnaire (PHQ-9). The presence of a lifetime history of PCa, other forms of cancer (except PCa) or absence of either was the main predictor variable.

RESULTS

An estimated 3.9% of men self-identified as having had a history of PCa diagnosis, 11.3% of men identified as having had a history of other forms of cancer and 84.9% reported never having had a diagnosis of cancer in their lifetime, respectively. Survivors of PCa had 2.45 or 2.05 statistically significantly higher odds of screening positive for current anxiety or depressive symptoms, respectively, compared with those who identified as without a lifetime history of any form of cancer in controlled analyses (including survivorship time).

CONCLUSIONS

Increased rates of anxiety and depression among men with a history of PCa highlight the need for mental health screening among PCa survivors. The findings highlight the importance of a multidisciplinary effort to prioritize and deliver comprehensive mental health support to PCa survivors.

Long-term functioning outcomes are predicted by cognitive symptoms in working patients with major depressive disorder treated with vortioxetine: results from the AtWoRC study

OBJECTIVE

AtWoRC (Assessment in Work productivity and the Relationship with Cognitive symptoms) was an interventional, open-label, Canadian study (NCT02332954) designed to assess the association between cognitive symptoms and workplace productivity in working patients with major depressive disorder (MDD) receiving vortioxetine.

METHODS

Eligible patients with MDD received vortioxetine (10-20 mg/day) and were assessed over 52 weeks at visits emulating a real-life setting (n = 199). Partial correlation between changes in patient-reported cognitive symptoms (20-item Perceived Deficits Questionnaire-Depression; PDQ-D-20) and workplace productivity (Work Limitations Questionnaire; WLQ) was assessed at 12 and 52 weeks. Additional assessments included depression severity, cognitive performance, and patient-reported functioning. Structural equations model (SEM) analyses assessed causal relationships between changes in measures of cognition and functioning over time, adjusted for improvements in depressive symptoms.

RESULTS

Statistically significant improvements in all outcomes from baseline to week 52 were seen in the overall population and both subgroups (first treatment and switch). Response and remission rates were 77% and 56%, respectively. Improvements in PDQ-D-20 and WLQ productivity loss scores at weeks 12 and 52 were significantly correlated. SEM analyses found patient-rated cognitive symptoms (PDQ-D-20) at weeks 12 and 26 were significantly predictive (p < 0.05) of patient-reported functioning (Sheehan Disability Scale) at the subsequent visit. Depression severity and objectively measured cognitive performance did not significantly predict functional outcomes at any timepoint.

CONCLUSION

These results demonstrate the long-term benefits of vortioxetine treatment in working patients with MDD and emphasize the strong association between cognitive symptoms and functioning in a real-world setting.

Functional electrical stimulation of the facial muscles to improve symptoms in individuals with major depressive disorder: pilot feasibility study

Background

Currently, the mainstay of treatment in patients diagnosed with major depressive disorder (MDD) requiring medical attention is second generation anti-depressants. However, about 40% of patients treated with second-generation anti-depressants do not respond to initial treatment and approximately 70% do not achieve remission during the first-step treatment. There are a few non-pharmacological options available, but none have shown consistently positive results. There is a need for an intervention that is relatively easy to administer, produces consistently positive results and is associated with minimal side effects. In the current study, we assessed the feasibility of using transcutaneous Functional Electrical Stimulation Therapy (FEST) of the facial muscles, as a tool for improving depressive symptoms in individuals with MDD.

Results

Ten (10) individuals with moderate to severe MDD received three FEST sessions/week for a minimum of 10 to a maximum of 40 sessions. All study participants completed the required 10 therapy sessions, and 5 of the 10 participants completed additional 30 (totalling 40) FEST sessions. There were no adverse events or concerns regarding compliance to therapy. We found statistically significant improvements on Hamilton Rating Scale for Depression (HDS) and Inventory of Depressive Symptomatology (IDS) measures. However, no significant improvements were found on Positive and Negative Affect Scale and 10-point Visual Analogue Scale scales. Participants reported improvements in sleeping patterns, and this correlated with statistically significant improvements on sleep parameters of HDS and IDS measures.

Conclusion

This study indicates that facial FEST is an acceptable, practical, and safe treatment in individuals with MDD. We provide preliminary evidence to show improvements in depressive symptoms following a minimum of 10 FEST sessions.

Cost-effectiveness analysis of a randomized study of depression treatment options in primary care suggests stepped-care treatment may have economic benefits

BACKGROUND

The stepped-care pathway (SCP) model has previously been found to be clinically effective for depressive disorder in some studies, but not all. Several groups have suggested that a stepped-care approach is the most appropriate in primary care. There is relatively little information, however, regarding which specific stepped-care pathway may be best. This analysis aimed to determine cost-effectiveness of a stepped-care pathway for depression in adults in primary care versus standard care (SC), treatment-as-usual (TAU), and online cognitive behavioural therapy (CBT).

METHODS

We conducted a randomized trial with 1400 participants and 12-week follow-up to assess the impact of the four treatment options on health-related quality of life and depression severity. Costs for the groups were calculated on the basis of physician, outpatient, and inpatient services using administrative data. We then calculated the incremental cost-effectiveness ratios using this information. Cost-effectiveness acceptability curves and incremental cost-effectiveness scatterplots were created using Monte Carlo simulation with 10,000 replications. A subgroup analysis was conducted for participants who screened as depressed at baseline.

RESULTS

For all participants, TAU was the most expensive followed by CBT, SC, and SCP. QALYs were highest in SCP, followed by SC, CBT, and TAU. In the depressed subgroup, TAU was still the most expensive, followed by SC, SCP, and CBT, while QALYs were still highest in SCP, followed by SC, CBT, and TAU. The cost-effectiveness acceptability curves suggested that SCP had a higher probability for cost-effectiveness than the other three alternatives in all participants. In the depressed subgroup, CBT was associated with the highest probability of cost-effectiveness for a willingness-to-pay cut-off of less than approximately $50,000, while SCP was the highest at a cut-off higher than $50,000. There is considerable uncertainty around the cost-effectiveness estimates.

CONCLUSIONS

Our analysis showed that even where there are no clinically significant differences in health outcomes between treatment approaches, there may be economic benefit from implementing the stepped-care model. While more work is required to identify the most clinically effective versions of a stepped-care pathway, our findings suggest that the care pathway may have potential to improve health care system value.

TRIAL REGISTRATION

NCT01975207 . The trial was prospectively registered on 4 November 2013.

Assessing the methodological quality of the Canadian Psychiatric Association's anxiety and depression clinical practice guidelines

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) endeavour to incorporate the best available research evidence together with the clinically informed opinions of leading experts in order to guide clinical practice when dealing with a given condition. There has been increased interest in CPGs that are evidence based and that promote best practice, a central component of which is incorporating the best available research predicated on strong study designs. Despite this soaring interest, there remains heterogeneity in the methodological quality of many CPGs, which may have an effect on the quality of services that clinicians offer. In light of this, this study examined the quality of the methodology used to develop two CPGs of the Canadian Psychiatric Association (CPA).

METHOD

The CPA's guidelines for the management of anxiety disorders (2006) and for the treatment of depressive disorders (2001) were assessed by trained raters using the Appraisal of Guidelines for Research and Evaluation II Instrument scale.

RESULTS

The blind ratings of three trained raters demonstrated that the anxiety and depression CPGs had a number of strengths and important weaknesses.

CONCLUSION

Implications for the development of future CPGs on anxiety and depression, including recommendations to improve guideline quality in psychiatry in particular, are discussed.

Cerebral MAO Activity Is Not Altered by a Novel Herbal Antidepressant Treatment

Inhibition of monoamine oxidase (MAO)-A/B can ameliorate depressive- and anxiety-related symptoms via increase of monoamine extracellular levels. However, such inhibition can also instigate hypertensive response following exposure to dietary tyramine (i.e., "the cheese effect"). Novel herbal treatment (NHT) is an herbal formula that has been demonstrated to reduce depressive- and anxiety-like symptoms in pre-clinical studies. The aim of the current study was to examine whether the therapeutic potential of NHT is underlain by inhibition of MAO-A/B and whether NHT poses a risk for tyramine hyper-potentiation. Unpredictable chronic mild stress (UCMS)-exposed mice and naïve mice were treated for 3 weeks with NHT (30 mg/kg; i.p.), the selective serotonin reuptake inhibitor (SSRI) escitalopram (15 mg/kg; i.p.), or saline. Subsequently, MAO-A/B activities in the hypothalamus, striatum, and prefrontal cortex (PFC) were assessed. Exposure to UCMS led to significant increases in both MAO-A and MAO-B activities in the hypothalamus (p < 0.001) and in the PFC (p < 0.01 for MAO-A; p < 0.001 for MAO-B). Neither NHT nor escitalopram had any notable effects. Treatment with NHT was supported as safe in terms of risk for inducing a hypertensive response. The antidepressant- and anxiolytic-like effects of NHT are mediated via pathways other than MAO-A/B inhibition.

Categorical improvement in functional impairment in depressed patients treated with desvenlafaxine

OBJECTIVE

This post-hoc pooled analysis evaluated categorical change in functional impairment in patients with major depressive disorder (MDD) treated with desvenlafaxine versus placebo and examined whether early improvement in functioning predicted functional outcomes at study endpoint.

METHODS

Data were pooled from eight randomized, double-blind, placebo-controlled studies of desvenlafaxine for the treatment of MDD, including adults who were randomly assigned to receive desvenlafaxine 50 or 100 mg/d or placebo (N=3,384). Shift tables were generated for categorical changes in functional impairment from baseline based on Sheehan Disability Scale (SDS) subscale scores. The categories were none/mild (0-3), moderate (4-6), and marked/extreme (7-10). Treatment comparisons for prespecified shifts of interest and predictive value of week 2 or 4 improvement in SDS subscale scores for functional outcome at week 8 were assessed using logistic regression.

RESULTS

Greater proportions of patients receiving desvenlafaxine 50 and 100 mg achieved improvement from baseline to week 8 for each prespecified shift endpoint versus placebo (all p ≤ 0.02). Early improvement in SDS subscale scores was a statistically significant predictor of functional outcome at week 8, both overall and for each treatment group (all p&lt;0.0001).

CONCLUSIONS

Treatment with desvenlafaxine 50 or 100 mg/d led to significantly greater categorical improvement in functional impairment versus placebo, and improvement in SDS subscale scores significantly predicted functional outcome. Monitoring patient progress early in the course of antidepressant treatment using a functional assessment such as the SDS may help clinicians determine whether or not treatment adjustments are needed.

Assessment in Work Productivity and the Relationship with Cognitive Symptoms (AtWoRC): primary analysis from a Canadian open-label study of vortioxetine in patients with major depressive disorder (MDD)

OBJECTIVE

The Assessment in Work Productivity and the Relationship with Cognitive Symptoms (AtWoRC) study aimed to assess the association between cognitive symptoms and work productivity in gainfully employed patients receiving vortioxetine for a major depressive episode (MDE).

METHODS

Patients diagnosed with major depressive disorder (MDD) and treated with vortioxetine independently of study enrollment were assessed over 52 weeks at visits that emulated a real-life setting. Patients were classified as those receiving vortioxetine as the first treatment for their current MDE (first treatment) or having shown inadequate response to a previous antidepressant (switch). The primary endpoint was the correlation between changes in patient-reported cognitive symptoms (20-item Perceived Deficits Questionnaire [PDQ-D-20]) and changes in work productivity loss (Work Limitations Questionnaire [WLQ]) at week 12. Additional assessments included changes in symptom and disease severity, cognitive performance, functioning, work loss, and safety.

RESULTS

In the week 12 primary analysis, 196 eligible patients at 26 Canadian sites were enrolled, received at least one treatment dose, and attended at least one postbaseline study visit. This analysis demonstrated a significant, strong correlation between PDQ-D-20 and WLQ productivity loss scores (r=0.634; p<0.001), and this correlation was significant in both first treatment and switch patients (p<0.001). A weaker correlation between Digit Symbol Substitution Test and WLQ scores was found (r=-0.244; p=0.003).

CONCLUSION

At 12 weeks, improvements in cognitive dysfunction were significantly associated with improvements in workplace productivity in patients with MDD, suggesting a role for vortioxetine in functional recovery in MDD.

Reliability and validity of the Japanese version of the Mental Health Self-management Questionnaire among people with mental illness living in the community

Background

Self-management is an important factor in maintaining and promoting mental health and recovery from mental health challenges. Thus, it is important to assess and support mental health self-management. In this study, we aimed to develop the Japanese version of the Mental Health Self-management Questionnaire (MHSQ-J), a scale to assess mental health self-management strategy, and clarify its psychometric properties among people with mental illness living in Japan.

Methods

An anonymous self-administered survey including MHSQ-J was conducted for psychiatric outpatient users (N = 295), and 104 of the participants completed MHSQ-J again about two weeks later. Internal consistency was assessed with Cronbach’s α, and test-retest reliability was confirmed by the intraclass correlation coefficient (ICC). Construct validity was assessed based on structural validity with confirmatory factor analysis (CFA) and exploratory factor analysis (EFA), and hypotheses testing. The Self-management Skill Scale, the University of Tokyo Health Sociology version of the Sense of Coherence Scale ver1.2, the Japanese version of Self-identified Stage of Recovery Part-B, the Japanese version of the Flourishing Scale, and the Japanese version of the WHO Disability Assessment Scale 2.0 were used for hypotheses testing.

Results

Data from 243 respondents were analyzed. The result of CFA, the goodness-of-fit indices showed marginal fit (AGFI = .830, CFI = .852, RMSEA = .072). EFA identified three factors (Clinical, Empowerment, and Vitality), and the results suggested that the factor structure of the Japanese version of MHSQ was similar to the original 3-factor structure. Significant correlations were found with the hypotheses testing variables related to self-management and recovery, especially on the total score, the Empowerment subscale, and the Vitality subscale. Cronbach’s α (Clinical: .65, Empowerment: .81, Vitality: .75, Total: .83) and ICC (Clinical: .75, 95% confidence interval (CI) [.62, .84], Empowerment: .81, 95% CI [.70, .88], Vitality: .62, 95% CI [.44, .75], Total: .84, 95% CI [.75, .90]) indicated good reliability.

Conclusion

The results show that MHSQ-J has acceptable reliability and validity to measure the use of self-management strategies for mental health among community living people with mental illness in Japan.

Electronic supplementary material

The online version of this article (10.1186/s40359-019-0301-4) contains supplementary material, which is available to authorized users.

[Frequency of physical symptoms in anxiety-depressive disorders: cross-sectional study in a population of 202 psychiatric consultants]

Introduction

les symptômes physiques associés aux troubles anxio-dépressifs ont fait l'objet de plusieurs études depuis plusieurs décennies, vu leurs fréquences et leurs conséquences. Le but de notre étude est de préciser la fréquence des principaux symptômes physiques dans les troubles anxieux: trouble panique (TP), trouble anxiété généralisée (TAG) et troubles phobiques (TPh), ainsi que dans les troubles dépressifs: épisode dépressif majeur (EDM) dans le cadre d'un trouble dépressif.

Méthodes

nous avons mené une étude transversale à visée descriptive, réalisée sur un échantillon de 202 consultants dans un service de psychiatrie.

Résultats

l'âge moyen des patients est de 42 ans (19 à 70 ans), avec une légère prédominance féminine: 118 (58%). Les troubles anxio-dépressifs constatés sont: l'EDM: 113(56%), le TP: 61 (30.2%), le TAG: 55 (27.2%) et les TPh: 30 (14.9%). La fréquence des patients présentant de 2 à 5, et plus de 5 symptômes était respectivement de 15.9% et 39.6% dans les troubles dépressifs, et de 9.5% et 62.9% dans les troubles anxieux. Les symptômes les plus rapportés sont d'ordre cardiopulmonaire (75%), général (73.8%) et neurologique (65.8%).

Conclusion

les symptômes physiques qui accompagnent les troubles anxio-dépressifs sont variables et souvent nombreux. Ils peuvent aggraver le pronostic de ces troubles psychiatriques en rendant difficile leur prise en charge. Un dépistage précoce de ces troubles, en portant une attention particulière à ces symptômes physiques, permettra de prévenir ces complications.