Measuring depression: comparison and integration of three scales in the GENDEP study

No effect of 5HTTLPR or BDNF Val66Met polymorphism on hippocampal morphology in major depression

Neuroimaging research implicates the hippocampus in the aetiology of major depressive disorder (MDD). Imaging genetics studies have investigated the influence of the serotonin transporter-linked polymorphic region (5HTTLPR) and brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on the hippocampus in healthy individuals and patients with depression (MDD). However, conflicting results have led to inconclusive evidence about the effect of 5HTTLPR or BDNF on hippocampal volume (HCV). We hypothesized that analysis methods based on three-dimensional (3D) hippocampal shape mapping could offer improved sensitivity to clarify these effects. Magnetic resonance imaging data were collected in parallel samples of 111 healthy individuals and 84 MDD patients. Manual hippocampal segmentation was conducted and the resulting data used to investigate the influence of 5HTTLPR and BDNF Val66Met genotypes on HCV and 3D shape within each sample. Hippocampal volume normalized by intracranial volume (ICV) showed no significant difference between 5HTTLPR S allele carriers and L/L homozygotes or between BDNF Met allele carriers and Val/Val homozygotes in the group of healthy individuals. Moreover, there was no significant difference in normalized HCV between 5HTTLPR diallelic and triallelic classifications or between the BDNF Val66Met genotypes in MDD patients, although there was a relationship between BDNF Val66Met and ICV. Shape analysis detected dispersed between-group differences, but these effects did not survive multiple testing correction. In this study, there was no evidence of a genetic effect for 5HTTLPR or BDNF Val66Met on hippocampal morphology in either healthy individuals or MDD patients despite the relatively large sample sizes and sensitive methodology.

Sexual dysfunction during treatment with serotonergic and noradrenergic antidepressants: clinical description and the role of the 5-HTTLPR

OBJECTIVES

Sexual dysfunction (SD) is a frequently reported side-effect of antidepressant treatment, particularly of selective serotonin reuptake inhibitors (SSRIs). In the multicentre clinical and pharmacogenetic GENDEP study (Genome-based Therapeutic Drugs for Depression), the effect of the serotonin transporter gene promoter polymorphism 5-HTTLPR on sexual function was investigated during treatment with escitalopram (SSRI) and nortriptyline (tricyclic antidepressant).

METHODS

A total of 494 subjects with an episode of DSM-IV major depression were randomly assigned to treatment with escitalopram or nortriptyline. Over 12 weeks, depressive symptoms and SD were measured weekly with the Montgomery-Asberg Depression Rating Scale, the Antidepressant Side-Effect Checklist, the UKU Side Effect Rating Scale, and the Sexual Functioning Questionnaire.

RESULTS

The incidence of reported SD after 12 weeks of treatment was relatively low, and did not differ significantly between antidepressants (14.9% escitalopram, 19.7% nortriptyline). There was no significant interaction between the 5-HTTLPR and antidepressant on SD. Improvement in depressive symptoms and younger age were both associated with lower SD. The effect of age on SD may have been moderated by the 5-HTTLPR.

CONCLUSIONS

In GENDEP, rates of reported SD during treatment were lower than those described in previous reports. There was no apparent effect of the 5-HTTLPR on the observed decline in SD.

Clinical and genetic correlates of suicidal ideation during antidepressant treatment in a depressed outpatient sample

AIMS

This study investigated clinical and genetic predictors of increasing suicidal ideation during antidepressant treatment.

MATERIALS & METHODS

A total of 131 depressed outpatients were allocated to four antidepressants (paroxetine, venlafaxine, clomipramine or nefazodone) in a sequential step procedure until remission. Suicidality was assessed using the 10th item of the Montgomery-Asberg Depression Rating Scale (MADRS). A total of 11 candidate genes involved in different mechanisms of antidepressant action were selected for association with increasing suicidality.

RESULTS

Increasing suicidality correlated with depression severity and higher antidepressant blood levels. Risk of increasing suicidal ideation was higher in subjects taking antidepressants other than paroxetine (odds ratio: 1.11). The strongest genetic predictor was found to be rs1360780 within the FKBP5 gene (p = 2.9 × 10(-5)), followed by 2677G>T in the ABCB1 gene. The rs130058 SNP within the 5-HTR1B gene demonstrated a differential association with increasing suicidal ideation depending on antidepressant type.

CONCLUSION

Increasing suicidal ideation might be an adverse effect of antidepressants. The involvement of FKBP5 indicates that dysregulation of the hypothalamic-pituitary-adrenal axis is involved in treatment increasing suicidal ideation.

The generalizability of antidepressant efficacy trials to routine psychiatric out-patient practice

BACKGROUND

Generalizability of antidepressant efficacy trials (AETs) to daily practice is questioned because of their very stringent patient selection. This study aims to determine eligibility for AETs of out-patients suffering from major depression in a routine out-patient setting and investigates influence of eligibility on treatment outcome.

METHOD

Data collection (n = 1653) was performed through routine outcome monitoring by independent trained research nurses. The Mini-International Neuropsychiatric Interview Plus and the Dimensional Assessment of Personality Pathology, short Dutch version were used for diagnostic assessment and personality pathology screening. The Montgomery-Asberg Depression Rating Scale (MADRS) was used for assessment of baseline severity and treatment outcome. Eligibility was assessed by stepwise application of commonly used exclusion criteria. Influence of eligibility on treatment outcome was investigated in a subsample of the 1653 patients who had at least one follow-up assessment (n = 626). Eligible and non-eligible patients were compared on proportion of response (50% reduction) and remission on MADRS (MADRS ≤ 10).

RESULTS

Altogether, 17-25% of the patients were eligible for AETs. The most common reasons for exclusion would be 'not meeting minimum baseline severity' and 'presence of co-morbid Axis I disorder'. Eligible and non-eligible patients did not differ in treatment outcome. Only 'meeting the minimum baseline severity' is associated with remission.

CONCLUSIONS

The majority of 'real life' out-patients are not eligible for AETs. However, the influence of eligibility on treatment outcome seems to be small. This suggests that stringent patient selection by eligibility criteria is not the major reason for lack of generalizability of AETs. Exclusion of less severely depressed patients from the analyses resulted in better treatment outcome. Milder depression is highly prevalent in daily practice and more research into treatment effectiveness in milder depression is warranted.

Melancholic, atypical and anxious depression subtypes and outcome of treatment with escitalopram and nortriptyline

OBJECTIVE

To investigate whether subtypes of depression predict differential outcomes of treatment with selective serotonin-reuptake inhibitor (SSRI) and a tricyclic antidepressant in major depression.

METHOD

Among 811 adults with moderate-to-severe depression, melancholic, atypical, anxious and anxious-somatizing depression subtypes established at baseline were evaluated as predictors of outcome of treatment with flexible dosage of the SSRI escitalopram or the tricyclic antidepressant nortriptyline. The primary outcome measure was the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures were the 17-item Hamilton Rating Scale for Depression (HRSD-17) and the Beck Depression Inventory (BDI).

RESULTS

Melancholic depression was associated with slightly worse outcomes among individuals treated with escitalopram, but did not affect outcome of treatment with nortriptyline. The interaction between melancholic depression and drug did not reach statistical significance for the primary outcome measure and significant results for secondary outcome measures were not robust in sensitivity analyses. Atypical depression was unrelated to outcome of treatment with either antidepressant. Anxious and anxious-somatizing depression did not predict outcome on the primary measure, but inconsistently predicted worse outcome in some secondary analyses.

LIMITATIONS

Some participants were non-randomly allocated to drug. Therefore, drug-by-predictor interactions had to be validated in sensitivity analyses restricted to the 468 randomly allocated individuals.

CONCLUSIONS

Melancholic, atypical or anxious depression, are not sufficiently robust differential predictors of outcome to help clinician choose between SSRI and tricyclic antidepressants. There is a need to investigate other predictors of outcome.

Variation in GNB3 predicts response and adverse reactions to antidepressants

There is substantial inter-individual variation in response and adverse reactions to antidepressants, and genetic variation may, in part, explain these differences. GNB3 encodes the β3 subunit of the G protein complex, which is involved in the downstream signalling cascade following monoamine receptor activation. A functional polymorphism in this gene (C825T) has been associated with response to antidepressants. Several lines of evidence suggest that GNB3 moderates improvement in the neurovegetative symptoms of depression (such as sleep and appetite) and related adverse reactions independently of change in core mood symptoms. We here report analysis of data from GENDEP, a part-randomized pharmacogenomic trial, on the outcome of 811 subjects with major depression undergoing treatment with either escitalopram or nortriptyline in which the C825T SNP and three further SNPs in GNB3 were genotyped. The TT genotype was significantly associated with a superior response to nortriptyline and these effects were specific to improvements in neurovegetative symptoms. In addition, the same genotype predicted fewer incidents of treatment-emergent insomnia and greater weight gain on the same drug. Our results are consistent with previous associations with GNB3 and emphasize the importance of signalling genes in antidepressant response.

Suicidal ideation during antidepressant treatment: do genetic predictors exist?

Suicidal thoughts during antidepressant treatment have recently been the focus of several candidate gene and genome-wide association studies. Although the clinical risk factors for such events are well known, unfortunately they do not help to predict who will have a suicidal event during antidepressant treatment and who will not. Pharmacogenomic studies have therefore attempted to use genetic variants to predict individual susceptibility to treatment-related suicidal ideation. In this perspective, several genetic predictors have been highlighted, the majority of which relate to common mechanisms of antidepressant action: genes involved in the neurotrophic and synaptic plasticity systems (CREB1, and BDNF and its receptor NTRK2), noradrenergic system (ADRA2A), glutamatergic system (GRIA3, GRIK2 and GDA), inflammatory and hypothalamic-pituitary-adrenal (HPA) axis systems (IL28RA and FKBP5) and in other brain functions (PAPLN, APOO, KCNIP4 and ELP3). Although some of these genes may be of interest in predicting antidepressant-induced suicidal ideation, they still need to be validated in better phenotypically designed samples. Several methodological factors are indeed responsible for the problems involved in implicating these findings in the causation of a clinically relevant phenotype. These include discrepancies between studies in defining phenotypes, with several different thresholds used to establish significant suicidal ideation; the use of scales not truly designed to measure suicidal ideation; and the paucity of true suicidal events (suicide attempts and/or completion) in pharmacogenomic studies. In conclusion, pharmacogenomic studies are far from fulfilling their promise. There is a need for future pharmacogenetic studies targeting events that are clinically significant in order to find associated variants that will help clinicians to improve their treatment strategies. While awaiting these genetic predictors, clinicians need to bear in mind that all studies in this field support a beneficial effect of antidepressants on suicidal ideation. This should therefore encourage them to prescribe antidepressant medication even in patients with suicidal ideation.

Changes in body weight during pharmacological treatment of depression

The risk of weight gain is an important determinant of the acceptability and tolerability of antidepressant medication. To compare changes in body weight during treatment with different antidepressants, body weight and height were measured at baseline and after 6, 8, 12 and 26 wk treatment with escitalopram or nortriptyline in 630 adults with moderate-to-severe unipolar depression participating in GENDEP, a part-randomized open-label study. Weight increased significantly more during treatment with nortriptyline compared to escitalopram. The weight gain commenced during the first 6 wk of nortriptyline treatment, reached on average 1.2 kg at 12 wk (0.44-point BMI increase), and continued throughout the 6-month follow-up period. Participants who were underweight at baseline gained most weight. Participants who were obese at baseline did not gain more weight during treatment. Weight gain occurred irrespective of whether weight loss was a symptom of current depressive episode and was identified as an undesired effect of the antidepressant by most participants who gained weight. There was little weight change during treatment with escitalopram, with an average increase of 0.14 kg (0.05-point BMI increase) over 12 wk of treatment. In conclusion, treatment with the tricyclic antidepressant nortriptyline was associated with moderate weight gain, which cannot be explained as a reversal of symptomatic weight loss and is usually perceived as an undesired adverse effect. While treatment with nortriptyline may be recommended in underweight subjects with typical neurovegetative symptoms, escitalopram is a suitable alternative for subjects at risk of weight gain.

Item response theory applied to the Beck Depression Inventory

The Beck Depression Inventory (BDI), a scale that measures the latent trait intensity of depression symptoms, can be assessed by the Item Response Theory (IRT). This study used the Graded-Response model (GRM) to assess the intensity of depressive symptoms in 4,025 individuals who responded to the BDI, in order to efficiently use the information available on different aspects enabled by the use of this methodology. The fit of this model was done in PARSCALE software. We identified 13 items of the BDI in which at least one response category was not more likely than others to be chosen, so that these items had to be categorized again. The items with greater power of discrimination were sadness, pessimism, feeling of failure, dissatisfaction, self-hatred, indecision, and difficulty of work. The most serious items were weight loss, suicidal ideas, and social withdrawal. The group of 202 individuals with the highest levels of depressive symptoms was comprised by 74% of women and almost 84% had a diagnosis of a psychiatric disorder. The results show gains resulting from use of IRT in the analysis of latent traits.

Measuring patients' views: a bifactor model of distinct patient-reported outcomes in psychosis

BACKGROUND

Patient-reported outcomes (PROs) are widely used for evaluating the care of patients with psychosis. Previous studies have reported a considerable overlap in the information captured by measures designed to assess different outcomes. This may impair the validity of PROs and makes an a priori choice of the most appropriate measure difficult when assessing treatment benefits for patients. We aimed to investigate the extent to which four widely established PROs [subjective quality of life (SQOL), needs for care, treatment satisfaction and the therapeutic relationship] provide distinct information independent from this overlap.

METHOD

Analyses, based on item response modelling, were conducted on measures of SQOL, needs for care, treatment satisfaction and the therapeutic relationship in two large samples of patients with psychosis.

RESULTS

In both samples, a bifactor model matched the data best, suggesting sufficiently strong concept factors to allow for four distinct PRO scales. These were independent from overlap across measures due to a general appraisal tendency of patients for positive or negative ratings and shared domain content. The overlap partially impaired the ability of items to discriminate precisely between patients from lower and higher PRO levels. We found that widely used sum scores were strongly affected by the general appraisal tendency.

CONCLUSIONS

Four widely established PROs can provide distinct information independent from overlap across measures. The findings may inform the use and further development of PROs in the evaluation of treatments for psychosis.

Ropinirole improves depressive symptoms and restless legs syndrome severity in RLS patients: a multicentre, randomized, placebo-controlled study

Comorbid depressive symptoms in restless legs syndrome (RLS) remain a treatment challenge, as some antidepressants aggravate RLS symptoms. Preliminary data in depressive patients suggest antidepressant properties of ropinirole. The present study investigates the effects of ropinirole immediate release (IR) on depressive symptoms and RLS severity. A multicenter, placebo-controlled, double-blind randomized (3:1) study was performed including patients with moderate to severe idiopathic RLS and at least mild depressive symptoms. Ropinirole IR (in flexible doses up to 4 mg/day) or placebo was given for 12 weeks including an uptitration phase of 7 weeks. Visits were scheduled at screening, baseline, and weeks 1, 4, and 12 with additional telephone contacts for dosing decisions. The modified intent to treat population comprised 231 patients (171 ropinirole, 60 placebo). The MADRS (Montgomery-Asberg Depression Rating Scale) scores decreased from baseline to week 12 from 18.8 to 8.7 in the ropinirole group and from 18.4 to 12.1 in the placebo group (primary endpoint, adjusted mean treatment difference -3.6 (95% CI: -5.6 to -1.6, significance in favor of ropinirole: P < 0.001). The superiority of ropinirole compared to placebo was confirmed by the Hamilton Scale for Depression and Beck Depression Inventory-II scores. RLS severity scores (IRLS) decreased by 14.7 (ropinirole) and by 9.9 (placebo, P < 0.001) points. Three out of four subdomains of the Medical Outcomes Study Sleep Scale improved significantly. The findings indicate that mild to moderate depressive symptoms should not be treated before sufficient therapy for RLS. Antidepressant medication can be necessary if depression symptoms still persist even if RLS symptoms are ameliorated.

Stressful life events, cognitive symptoms of depression and response to antidepressants in GENDEP

BACKGROUND

The occurrence of stressful life events (SLEs) has been shown to predict response to antidepressants; however, results are inconsistent. There is some evidence to suggest that SLEs prior to treatment are associated with greater cognitive symptoms at baseline and may therefore predict changes in these symptoms specifically.

METHODS

GENDEP, a prospective part-randomised pharmacogenomics trial, collected longitudinal data on the symptoms of patients with major depression treated with either a selective serotonin reuptake inhibitor (SSRI, escitalopram) or a tricyclic antidepressant (TCA, nortriptyline). Data on life events experienced in the 6 months preceding treatment measured using the List of Threatening Experiences Questionnaire (LTE-Q) were available for 728 participants.

RESULTS

Both the occurrence and number of SLEs were associated with greater cognitive but not mood or neurovegetative symptoms prior to treatment. Those who reported SLEs also experienced a greater decline in cognitive symptoms during treatment with escitalopram, but not with nortriptyline.

LIMITATIONS

Life events were measured retrospectively using a self-report checklist and are therefore subject to a number of biases especially in the context of depressive illness.

CONCLUSIONS

These findings are in line with cognitive theories of depression and suggest that symptomatic heterogeneity may have contributed to inconsistencies in studies reported to date. Our results also tentatively suggest a clinically relevant drug specific effect of SLEs. Specifically, those reporting stress may benefit more from treatment with SSRIs than TCAs.

Overview of the genetics of major depressive disorder

Major depressive disorder (MDD) is a common psychiatric illness with high levels of morbidity and mortality. Despite intensive research during the past several decades, the neurobiological basis and pathophysiology of depressive disorders remain unknown. Genetic factors play important roles in the development of MDD, as indicated by family, twin, and adoption studies, and may reveal important information about disease mechanisms. This article describes recent developments in the field of psychiatric genetics, with a focus on MDD. Early twin studies, linkage studies, and association studies are discussed. Recent findings from genome-wide association studies are reviewed and future directions discussed. Despite all efforts, thus far, no single genetic variation has been identified to increase the risk of depression substantially. Genetic variants are expected to have only small effects on overall disease risk, and multiple genetic factors in conjunction with environmental factors are likely necessary for the development of MDD. Future large-scale studies are needed to dissect this complex phenotype and to identify pathways involved in the etiology of MDD.

Discrepancy between subjective and objective severity in treatment-resistant depression: prediction of treatment outcome

OBJECTIVE

Identifying predictors of outcome among patients with treatment-resistant depression (TRD) is challenging. We hypothesised that discrepancy between self-rated and observer-rated scales may be a simple way of making such a prediction.

METHOD

102 patients were admitted to a unit specialising in the treatment of resistant depression and underwent fortnightly assessment with clinician-rated (Hamilton Depression Rating Scale-21, HAM-D) and self-rated (Beck Depression Inventory, BDI) measures. All patients had significant depressive symptoms that were treatment resistant, 70% as part of a major depressive disorder and the remainder as part of a bipolar or other disorder. A discrepancy score between the HAM-D and BDI was calculated on admission and its association with patient clinico-demographic factors was determined. A subset of 67 patients remained as inpatients for 40 weeks or until clinical response and were entered into a responder analysis, in which response was defined as ≥50% reduction in admission HAM-D score. The association of the admission BDI-HAM-D discrepancy score with subsequent patient response, was determined.

RESULTS

The magnitude of BDI-HAM-D discrepancy was higher in those with co-morbid personality disorder, lower in those with psychosis and positively correlated with anxiety. High BDI-HAM-D discrepancy score predicted delayed treatment response (odds ratio 5.40, p = 0.005).

CONCLUSION

Within TRD, higher discrepancy predicts slower response to treatment independent of objective illness severity; this may be mediated by underlying personality traits and co-morbid anxiety.

Regional brain metabolic correlates of self-reported depression severity contrasted with clinician ratings

BACKGROUND

We compared brain-map correlations of relative cerebral glucose metabolism (rCMRglu) with psychopathologic factors derived from the self-rated Beck Depression Inventory (BDI) and factors from the clinician-rated Hamilton Depression Rating Scale (HDRS) factors, seeking an anatomic basis for differences in self and clinician ratings.

METHODS

[(18)F]-FDG Positron Emission Tomography generated rCMRglu, SPM-estimated, voxel-level, brain correlation maps with BDI factor scores and HDRS factor scores in medication-free major depressive disorder.

RESULTS

Regional brain correlates of BDI are more extensive than HDRS, even when adjusting for variance accounted for by the HDRS. Factors comprising the BDI were associated with distinct cortical and subcortical regions. The degree of overlap in factor correlation brain maps is explained by the variance shared by BDI and HDRS factor scores.

CONCLUSION

Self and clinician-rated aspects of depression have common and distinct neuroanatomic correlates that reflect correlations between rating scales, but correlations between glucose metabolism and self-rated depression were anatomically more extensive in this sample. Findings highlight the importance and biological underpinnings of these subjective features of major depression.

Genome-wide association study of increasing suicidal ideation during antidepressant treatment in the GENDEP project

Suicidal thoughts during antidepressant treatment have been the focus of several candidate gene association studies. The aim of the present genome-wide association study was to identify additional genetic variants involved in increasing suicidal ideation during escitalopram and nortriptyline treatment. A total of 706 adult participants of European ancestry, treated for major depression with escitalopram or nortriptyline over 12 weeks in the Genome-Based Therapeutic Drugs for Depression (GENDEP) study were genotyped with Illumina Human 610-Quad Beadchips (Illumina, San Diego, CA, USA). A total of 244 subjects experienced an increase in suicidal ideation during follow-up. The genetic marker most significantly associated with increasing suicidality (8.28 × 10(-7)) was a single-nucleotide polymorphism (SNP; rs11143230) located 30 kb downstream of a gene encoding guanine deaminase (GDA) on chromosome 9q21.13. Two suggestive drug-specific associations within KCNIP4 (Kv channel-interacting protein 4; chromosome 4p15.31) and near ELP3 (elongation protein 3 homolog; chromosome 8p21.1) were found in subjects treated with escitalopram. Suggestive drug by gene interactions for two SNPs near structural variants on chromosome 4q12, one SNP in the apolipoprotein O (APOO) gene on chromosome Xp22.11 and one on chromosome 11q24.3 were found. The most significant association within a set of 33 candidate genes was in the neurotrophic tyrosine kinase receptor type 2 (NTRK2) gene. Finally, we also found trend for an association within genes previously associated with psychiatric phenotypes indirectly linked to suicidal behavior, that is, GRIP1, NXPH1 and ANK3. The results suggest novel pathways involved in increasing suicidal ideation during antidepressant treatment and should help to target treatment to reduce the risk of this dramatic adverse event. Limited power precludes definitive conclusions and replication in larger sample is warranted.

Pharmacogenetics of antidepressive treatment

The search of the genetic predictors of response to antidepressants is a rapidly expanding field. A large number of clinical studies are reporting partly inconsistent results. Emerging new results focus on new candidate single nucleotide polymorphisms--particularly in the 5HT2a-receptor gene and the gene coding for the co-chaperone FKBP5. The impact of the 5HTTLPR polymorphism on therapeutic outcome and side effects under treatment with SSRIs has to be viewed in a more complex manner than previously proposed. All replicable genetic associations display only a very modest effect. Despite of enormous research efforts, currently pharmacogenetics of therapeutic effects and of side effects of antidepressants are unable to guide decisions on the selection of the most beneficial drug for an individual patient.

Trajectories of change in depression severity during treatment with antidepressants

BACKGROUND

Response and remission defined by cut-off values on the last observed depression severity score are commonly used as outcome criteria in clinical trials, but ignore the time course of symptomatic change and may lead to inefficient analyses. We explore alternative categorization of outcome by naturally occurring trajectories of symptom change.

METHOD

Growth mixture models were applied to repeated measurements of depression severity in 807 participants with major depression treated for 12 weeks with escitalopram or nortriptyline in the part-randomized Genome-based Therapeutic Drugs for Depression study. Latent trajectory classes were validated as outcomes in drug efficacy comparison and pharmacogenetic analyses.

RESULTS

The final two-piece growth mixture model categorized participants into a majority (75%) following a gradual improvement trajectory and the remainder following a trajectory with rapid initial improvement. The rapid improvement trajectory was over-represented among nortriptyline-treated participants and showed an antidepressant-specific pattern of pharmacogenetic associations. In contrast, conventional response and remission favoured escitalopram and produced chance results in pharmacogenetic analyses. Controlling for drop-out reduced drug differences on response and remission but did not affect latent trajectory results.

CONCLUSIONS

Latent trajectory mixture models capture heterogeneity in the development of clinical response after the initiation of antidepressants and provide an outcome that is distinct from traditional endpoint measures. It differentiates between antidepressants with different modes of action and is robust against bias due to differential discontinuation.

Housekeeping gene expression is affected by antidepressant treatment in a mouse fibroblast cell line

Quantitative real-time polymerase chain reaction (PCR) is an effective approach in investigating the effects of exogenous compounds on gene expression. This is often achieved by exploiting so-called 'housekeeping' genes as baseline controls to normalise expression levels, which have historically been assumed to have a relatively stable expression pattern. Recent non-in-vitro studies have questioned the validity of this, but previous in-vitro data were lacking following antidepressant treatment. We here investigated the stability of 12 housekeeping genes during treatment of the mouse L929 fibroblast cell line with escitalopram and nortriptyline. Cells were cultured in the presence of antidepressant at 1 microM or 10 microM for 30 min, 24 h or 48 h, and RNA subjected to quantitative PCR (qPCR). Stability of relative transcript expression values was assessed via gene-gene expression ratios and intra- and inter-group variation (using geNorm and NormFinder programs). The three most stable transcripts were adenosine triphosphate (ATP) synthase, H+ transporting mitochondrial F1 complex, beta subunit, beta-2 microglobulin and cytochrome c-1. The least stable were Gapdh, eukaryotic translation initiation factor 4A2 and Calnexin (Canx). In conclusion, care must be taken when choosing reference transcripts for analysis in qPCR. For in-vitro pharmacological studies, it should not be assumed that 'housekeeping' genes are stable.

Do fall predictors in middle aged and older adults predict fall status in persons 50+ with fibromyalgia? An exploratory study

We explored potential predictors of fall status in 70 community-dwelling persons > or =50 years of age with fibromyalgia (FM). Over 40% of the sample reported one or more falls in the year prior to the study. A logistic regression model using 10 variables known to predict falls in middle aged and older persons predicted 45% of the variance in fall status. Three variables offered significant independent contributions to the overall model predicting fall status: perception of postural instability, balance performance, and executive function processing speed. The results support prior work in both nonclinical and clinical populations of middle aged and older adults indicating that falls are associated with multiple risk factors. Prospective designs with larger samples are needed to (a) validate and extend these findings, and (b) identify risk factors related to fall status that are unique to persons with FM.

History of suicide attempts among patients with depression in the GENDEP project

BACKGROUND

It has been proposed that a history of suicide attempts could be a correlate of severe depressive disorder and that suicide attempters (SA) could represent a particular subtype of subjects suffering from major depressive disorder. We investigated clinical and demographic characteristics associated with SA and tested the hypothesis that a history of suicide attempts predicts poor response to antidepressants.

METHODS

One-hundred-and-forty-one SA and 670 non-SA subjects with major depressive disorder (MDD) were treated for twelve weeks with escitalopram or nortriptyline in GENDEP, a part-randomized multi-center clinical and pharmacogenetic study. Baseline characteristics were compared using linear and logistic regression. Linear mixed models were used to analyse continuous outcomes during the twelve weeks of follow-up.

RESULTS

At baseline, SA subjects suffered from more severe depression (mean Montgomery-Asberg Depression Rating Scale: 30.29 (7.61) vs 28.43 (6.54), p=0.0002), reported higher level of suicidal ideation (1.21 (0.82) vs 0.73 (0.48), p<0.0001), had a younger age of onset and experienced more depressive episodes, had higher harm avoidance scores and poorer socio-demographic environment than non-SA individuals. However, during the twelve weeks of treatment and after adjustment for baseline severity of depression there was no difference in treatment response between SA and non-SA.

LIMITATIONS

Due to its retrospective design, it is possible that more severely depressed subjects might report more suicide attempts than less depressed individuals.

CONCLUSIONS

While SA differed from non-SA in several clinical and demographic characteristics, the antidepressants were similarly effective in SA as in comparably severely depressed subjects without a history of suicide attempts.

The International Consortium on Lithium Genetics (ConLiGen): an initiative by the NIMH and IGSLI to study the genetic basis of response to lithium treatment

For more than half a decade, lithium has been successfully used to treat bipolar disorder. Worldwide, it is considered the first-line mood stabilizer. Apart from its proven antimanic and prophylactic effects, considerable evidence also suggests an antisuicidal effect in affective disorders. Lithium is also effectively used to augment antidepressant drugs in the treatment of refractory major depressive episodes and prevent relapses in recurrent unipolar depression. In contrast to many psychiatric drugs, lithium has outlasted various pharmacotherapeutic 'fashions', and remains an indispensable element in contemporary psychopharmacology. Nevertheless, data from pharmacogenetic studies of lithium are comparatively sparse, and these studies are generally characterized by small sample sizes and varying definitions of response. Here, we present an international effort to elucidate the genetic underpinnings of lithium response in bipolar disorder. Following an initiative by the International Group for the Study of Lithium-Treated Patients (www.IGSLI.org) and the Unit on the Genetic Basis of Mood and Anxiety Disorders at the National Institute of Mental Health,lithium researchers from around the world have formed the Consortium on Lithium Genetics (www.ConLiGen.org) to establish the largest sample to date for genome-wide studies of lithium response in bipolar disorder, currently comprising more than 1,200 patients characterized for response to lithium treatment. A stringent phenotype definition of response is one of the hallmarks of this collaboration. ConLiGen invites all lithium researchers to join its efforts.

In Bangladesh, overweight individuals have fewer symptoms of depression than nonoverweight individuals

The aim of this study was to examine whether the association between overweight and depression usually found in western societies would also be found in locations where overweight is not stigmatized. A total of 1,271 individuals from rural Bangladesh were randomly selected; the response rate was 76%. Depressive symptoms were measured with the Montgomery-Asberg Depression Rating Scale (MADRS). The sum MADRS scores were 13.4 (s.d. = 5.8) and 18.5 (8.1) for overweight vs. nonoverweight (t = 6.6; P < 0.000) men, respectively, and 19.7 (7.8) and 23.2 (7.9) for overweight vs. nonoverweight women, respectively (t = 4.2; P < 0.000). Thus the MADRS score was lower in overweight individuals. After adjusting for sex and age, BMI significantly predicted the MADRS score (beta = -0.3; t = 10.2; P < 0.000). These findings suggest that overweight may be related to fewer depressive symptoms in non western cultures.

Self- and clinician-rated Montgomery-Asberg Depression Rating Scale: evaluation in clinical practice

BACKGROUND

Time- and cost-effective self-rating scales of depressive symptoms are particularly valuable for frequent use in large-scale effectiveness trials. The aim of the present study was to examine the psychometric properties of the French version of the self-rated Montgomery-Asberg Depression Rating Scale (MADRS-S) and determine whether it might complement the MADRS in monitoring depression severity and change over time in routine clinical practice.

METHODS

Sixty-three adult outpatients with a current depressive episode completed the MADRS-S and were interviewed with the MADRS on two occasions, within a 1-month interval.

RESULTS

All patients readily accepted the MADRS-S. It showed good to excellent internal consistency (Cronbach's alpha 0.85 at Time 1; 0.94 at Time 2). Its factor structure revealed that a single component explained a large proportion of variability (47.0% at Time 1; 68.8% at Time 2). Concurrent validity of the self- and clinician-rated versions was good (Pearson's correlation coefficients for total scores 0.81 at Time 1; 0.91 at Time 2). The MADRS-S was sensitive to change over the 4-week observation period (correlation of 0.71 between change scores on self- and clinician-rated instruments).

LIMITATIONS

Generalizability is restricted to outpatients with moderate to severe depression, and the MADRS-S ability to measure treatment effects needs to be examined.

CONCLUSIONS

The present study indicates that the MADRS-S displays favourable psychometric properties and suggests that it might be a valid complement to the MADRS, both in research settings and clinical practice.

The Everyday Feeling Questionnaire: the structure and validation of a measure of general psychological well-being and distress

BACKGROUND

Psychological distress and well-being underlie the continuum of susceptibility to common mental disorders. Our objective was to provide a simple and acceptable measure of psychological distress and well-being to collect information from subjects and informants in non-clinical samples, to explore its internal structure, concurrent and external validity.

METHOD

Self and partner versions of the ten-item Everyday Feeling Questionnaire (EFQ) were administered to 5,279 adults. The 12-item General Health Questionnaire (GHQ) was used to establish concurrent validity. Socioeconomic status, child psychopathology, and family functioning served as external validators.

RESULTS

The EFQ was internally consistent with all items loading strongly on a single common factor. Item response analysis showed excellent sensitivity of the ten items, balanced contribution of well-being and distress items and good information content across a broad range. The internal structure of partner version did not differ from self-report. The constructs measured by the EFQ and GHQ were distinct, but highly correlated. The EFQ's correlations with external validators were stronger than GHQ's ones.

CONCLUSION

Psychological well-being and distress are measurable as a single construct, using the EFQ. The partner-report version will facilitate the collection of data on multiple household members or on the same individual from two or more sources.

Depressive symptoms in persons with acute coronary syndrome: specific symptom scales and prognosis

OBJECTIVE

To determine which particular depressive symptom scales, derived from three scales, predicted poorer prognosis in persons with acute coronary syndrome (ACS).

METHODS

Hospitalized ACS patients (n=408) completed questionnaires (depression, vital exhaustion). Mokken scaling derived unidimensional scales. Major cardiac events (cardiac mortality, ACS, unplanned revascularization) were assessed at median 67 weeks post event.

RESULTS

Only depressive symptoms of fatigue-sadness predicted prognosis in univariate (hazard ratio [HR]=1.8, 95% CI 1.1-3.0, P=.025) and multivariate analysis (HR=1.8, 95% CI 1.1-2.9, P=.025). Symptoms of anhedonia (HR=1.6, 95% CI 0.9-2.8, P=.102) and depressive cognitions (HR=1.3, 95% CI 0.7-2.2, P=.402) did not.

CONCLUSION

Symptoms of fatigue-sadness, but not other symptoms, were associated with increased risk of major cardiac events. Depression should be considered as a multidimensional, rather than a unidimensional, entity when designing interventions.

Physical performance as a predictor of attention and processing speed in fibromyalgia

Cherry BJ, Weiss J, Barakat BK, Rutledge DN, Jones CJ. Physical performance as a predictor of attention and processing speed in fibromyalgia.

OBJECTIVE

To explore the associations between physical (both self-report and objective measures) and cognitive function for persons with fibromyalgia (FM).

DESIGN

Correlational study.

SETTING

An exercise testing laboratory in southern California.

PARTICIPANTS

Community-residing and functionally independent (not wheelchair-bound) adults meeting the American College of Rheumatology 1990 criteria for FM (N=51) with a mean age of 54 years and no history of stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Composite Physical Function Scale, Fibromyalgia Impact Questionnaire, adapted Trail Making Test parts A (TMT-A) and B (TMT-B), Digit Symbol Substitution Test, a composite index of TMT-A, TMT-B, and Digit Symbol Substitution Test combined, and physical performance assessments.

RESULTS

Hierarchical regression analyses indicated that better objective physical performance predicted increased cognitive function for TMT-A and the composite cognitive score after controlling for age and symptom burden. That is, as the physical performance level decreased, cognitive performance levels decreased.

CONCLUSIONS

Findings suggest that research is needed to determine whether patterns of physical activity participation, through their effects on physical fitness and performance, can enhance cognitive performance in persons with FM. Physiologic changes in specific brain regions in FM (eg, hippocampus, neural pain regions) suggest that further research is also warranted in determining specific relationships between biomarkers and cognitive performance in persons with FM.

Genetic predictors of increase in suicidal ideation during antidepressant treatment in the GENDEP project

The aim of this study was to investigate genetic predictors of an increase in suicidal ideation during treatment with a selective serotonin reuptake inhibitor or a tricyclic antidepressant. A total of 796 adult patients with major depressive disorder who were treated with a flexible dosage of escitalopram or nortriptyline in Genome-based Therapeutic Drugs for Depression (GENDEP) were included in the sample and provided data on suicidal ideation. Nine candidate genes involved in neurotrophic, serotonergic, and noradrenergic pathways were selected based on previous association studies with suicidal ideation or behavior. Using a logistic regression model, 123 polymorphisms in these genes were compared between subjects with an increase in suicidal ideation and those without any increase in suicidal ideation. Polymorphisms in BDNF, the gene encoding the brain-derived neurotrophic factor, were significantly associated with an increase in suicidal ideation. The strongest association was observed for rs962369 in BDNF (p=0.0015). Moreover, a significant interaction was found between variants in BDNF and NTRK2, the gene encoding the BNDF receptor (p=0.0003). Among men taking nortriptyline, suicidality was also associated with rs11195419 SNP in the alpha(2A)-adrenergic receptor gene (ADRA2A) (p=0.007). The associations observed with polymorphisms in BDNF suggest the involvement of the neurotrophic system in vulnerability to suicidality. Epistasis between BDNF and NTRK2 suggests that genetic variations in the two genes are involved in the same causal mechanisms leading to suicidality during antidepressant treatment. Among men, genetic variation in noradrenergic signaling may interact with norepinephrine reuptake-inhibiting antidepressants, thereby contributing to suicidality.

Body weight as a predictor of antidepressant efficacy in the GENDEP project

BACKGROUND

Being overweight or obese may be associated with poor response to antidepressants. The present report explores the moderation of antidepressant response by body weight to establish the specificity to antidepressant mode of action, type of depressive symptoms and gender.

METHODS

Height and weight were measured in 797 men and women with major depression treated with escitalopram or nortriptyline for twelve weeks as part of the Genome Based Therapeutic Drugs for Depression (GENDEP) project. Body mass index (BMI) and obesity (BMI>30) were tested as predictors of change in depressive symptoms using mixed linear models.

RESULTS

Higher BMI and obesity predicted poor response to nortriptyline but did not significantly influence response to escitalopram. The moderation of response by body weight was due to differential improvement in neurovegetative symptoms, including sleep and appetite. The relationship between body weight and change in neurovegetative symptoms was moderated by gender with obese men responding less to nortriptyline and obese women having poorer response to both antidepressants.

LIMITATIONS

As no placebo arm was included, the specificity of findings to antidepressants is relative. Lack of specific measures precluded accounting for differences in body fat distribution.

CONCLUSIONS

Body weight should be considered in the assessment of depression as it may inform the selection of antidepressant treatment.

Association of the metabolic syndrome with depression and anxiety in Japanese men: a 1-year cohort study

BACKGROUND

Recent studies on the association between the metabolic syndrome (MetS) and depression have reported conflicting findings. This 1-year cohort study aims to evaluate the association of MetS with the development of both depression and anxiety.

METHODS

The cohort comprised 956 Japanese male employees of an enterprise (mean age, 42.7 years; SD, 10.2 years). MetS was diagnosed according to the International Diabetes Federation criteria. The psychological conditions of depression and anxiety were assessed in 2 successive years by using the profile of mood states (POMS) questionnaire and by conducting clinical interviews as per the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). We evaluated the temporal and dose-response relationships between MetS and the development of depression and anxiety, controlling for potential confounding factors like age and lifestyle-related factors.

RESULTS

We identified a positive relationship between MetS at baseline and new-onset depression in the subsequent year (OR 2.14, 95% CI 1.10-4.17). Of the five MetS components examined, only waist circumference was significantly related to new-onset depression (OR 2.08, 1.23-3.50). Trend analysis revealed a significant positive trend of association between the number of MetS components identified and new-onset depression (P(trend) < 0.01), but not between Mets and new-onset anxiety.

CONCLUSIONS

Our results suggest that MetS is a predictive factor for the development of depression, and that waist circumference largely contributes to the association between MetS and depression.

Applied psychometrics in clinical psychiatry: the pharmacopsychometric triangle

OBJECTIVE

To consider applied psychometrics in psychiatry as a discipline focusing on pharmacopsychology rather than psychopharmacology as illustrated by the pharmacopsychometric triangle.

METHOD

The pharmacopsychological dimensions of clinically valid effects of drugs (antianxiety, antidepressive, antimanic, and antipsychotic), of clinically unwanted effects of these drugs, and the patients' own subjective perception of the balance between wanted and unwanted effects are analysed using rating scales assessed by modern psychometric tests (item response theory models)

RESULTS

Symptom rating scales fulfilling the item response theory models have been shown to be psychometrically valid outcome scales as their total scores are sufficient statistics for demonstrating dose-response relationship within the various classes of antianxiety, antidepressive, antimanic or antipsychotic drugs. The total scores of side-effect rating scales are, however, not sufficient statistics, implying that each symptom has to be analysed individually. Self-rating scales with very few items appear to be sufficient statistics when measuring the patients' own perception of quality of life.

CONCLUSION

Applied psychometrics in psychiatry have been found to cover a pharmacopsychometric triangle illustrating the measurements of wanted and unwanted effects of pharmacotherapeutic drugs as well as health-related quality of life.

Suicidal ideation during treatment of depression with escitalopram and nortriptyline in genome-based therapeutic drugs for depression (GENDEP): a clinical trial

BACKGROUND

Suicidal thoughts and behaviours during antidepressant treatment, especially during the first weeks of treatment, have prompted warnings by regulatory bodies. The aim of the present study is to investigate the course and predictors of emergence and worsening of suicidal ideation during tricyclic antidepressant and serotonin reuptake inhibitor treatment.

METHODS

In a multicentre part-randomised open-label study, 811 adult patients with moderate to severe unipolar depression were allocated to flexible dosage of escitalopram or nortriptyline for 12 weeks. The suicidality items of three standard measures were integrated in a suicidal ideation score. Increases in this score were classified as treatment emergent suicidal ideation (TESI) or treatment worsening suicidal ideation (TWOSI) according to the absence or presence of suicidal ideation at baseline.

RESULTS

Suicidal ideation decreased during antidepressant treatment. Rates of TESI and TWOSI peaked in the fifth week. Severity of depression predicted TESI and TWOSI. In men, nortriptyline was associated with a 9.8-fold and 2.4-fold increase in TESI and TWOSI compared to escitalopram, respectively. Retirement and history of suicide attempts predicted TWOSI.

CONCLUSION

Increases in suicidal ideation were associated with depression severity and decreased during antidepressant treatment. In men, treatment with escitalopram is associated with lower risk of suicidal ideation compared to nortriptyline. Clinicians should remain alert to suicidal ideation beyond the initial weeks of antidepressant treatment.

TRIAL REGISTRATION

EudraCT (No.2004-001723-38) and ISRCTN (No. 03693000).

Adverse reactions to antidepressants

BACKGROUND

Adverse drug reactions are important determinants of non-adherence to antidepressant treatment, but their assessment is complicated by overlap with depressive symptoms and lack of reliable self-report measures.

AIMS

To evaluate a simple self-report measure and describe adverse reactions to antidepressants in a large sample.

METHOD

The newly developed self-report Antidepressant Side-Effect Checklist and the psychiatrist-rated UKU Side Effect Rating Scale were repeatedly administered to 811 adult participants with depression in a part-randomised multicentre open-label study comparing escitalopram and nortriptyline.

RESULTS

There was good agreement between self-report and psychiatrists' ratings. Most complaints listed as adverse reactions in people with depression were more common when they were medication-free rather than during their treatment with antidepressants. Dry mouth (74%), constipation (33%) and weight gain (15%) were associated with nortriptyline treatment. Diarrhoea (9%), insomnia (36%) and yawning (16%) were more common during treatment with escitalopram. Problems with urination and drowsiness predicted discontinuation of nortriptyline. Diarrhoea and decreased appetite predicted discontinuation of escitalopram.

CONCLUSIONS

Adverse reactions to antidepressants can be reliably assessed by self-report. Attention to specific adverse reactions may improve adherence to antidepressant treatment.

Standardised rating scales in psychiatry: methodological basis, their possibilities and limitations and descriptions of important rating scales

Standardized rating scales are an important tool to improve the assessment of psychopathological symptoms in terms of validity and reliability. Especially observer-rated scales are of primary importance in this respect. Self-rating scales can give a meaningful complementary view to the findings of observer-rated scales. Besides scales covering more or less the whole spectrum of psychopathological symptoms, specialised scales focussing only on symptoms of disorders like schizophrenia or depression were developed. They are widely used, specifically for pragmatic reasons.

Moderation of antidepressant response by the serotonin transporter gene

BACKGROUND

There have been conflicting reports on whether the length polymorphism in the promoter of the serotonin transporter gene (5-HTTLPR) moderates the antidepressant effects of selective serotonin reuptake inhibitors (SSRIs). We hypothesised that the pharmacogenetic effect of 5-HTTLPR is modulated by gender, age and other variants in the serotonin transporter gene.

AIMS

To test the hypothesis that the 5-HTTLPR differently influences response to escitalopram (an SSRI) compared with nortriptyline (a noradrenaline reuptake inhibitor).

METHOD

The 5-HTTLPR and 13 additional markers across the serotonin transporter gene were genotyped in 795 adults with moderate-to-severe depression treated with escitalopram or nortriptyline in the Genome Based Therapeutic Drugs for Depression (GENDEP) project.

RESULTS

The 5-HTTLPR moderated the response to escitalopram, with long-allele carriers improving more than short-allele homozygotes. A significant three-way interaction between 5-HTTLPR, drug and gender indicated that the effect was concentrated in males treated with escitalopram. The single-nucleotide polymorphism rs2020933 also influenced outcome.

CONCLUSIONS

The effect of 5-HTTLPR on antidepressant response is SSRI specific conditional on gender and modulated by another polymorphism at the 5' end of the serotonin transporter gene.

Genetic predictors of response to antidepressants in the GENDEP project

The objective of the Genome-based Therapeutic Drugs for Depression study is to investigate the function of variations in genes encoding key proteins in serotonin, norepinephrine, neurotrophic and glucocorticoid signaling in determining the response to serotonin-reuptake-inhibiting and norepinephrine-reuptake-inhibiting antidepressants. A total of 116 single nucleotide polymorphisms in 10 candidate genes were genotyped in 760 adult patients with moderate-to-severe depression, treated with escitalopram (a serotonin reuptake inhibitor) or nortriptyline (a norepinephrine reuptake inhibitor) for 12 weeks in an open-label part-randomized multicenter study. The effect of genetic variants on change in depressive symptoms was evaluated using mixed linear models. Several variants in a serotonin receptor gene (HTR2A) predicted response to escitalopram with one marker (rs9316233) explaining 1.1% of variance (P=0.0016). Variants in the norepinephrine transporter gene (SLC6A2) predicted response to nortriptyline, and variants in the glucocorticoid receptor gene (NR3C1) predicted response to both antidepressants. Two HTR2A markers remained significant after hypothesis-wide correction for multiple testing. A false discovery rate of 0.106 for the three strongest associations indicated that the multiple findings are unlikely to be false positives. The pattern of associations indicated a degree of specificity with variants in genes encoding proteins in serotonin signaling influencing response to the serotonin-reuptake-inhibiting escitalopram, genes encoding proteins in norepinephrine signaling influencing response to the norepinephrine-reuptake-inhibiting nortriptyline and a common pathway gene influencing response to both antidepressants. The single marker associations explained only a small proportion of variance in response to antidepressants, indicating a need for a multivariate approach to prediction.

Proton MR spectroscopy of the hippocampus at 3 T in patients with unipolar major depressive disorder: correlates and predictors of treatment response

Various lines of research suggest that neurotrophic processes in the hippocampus are key mechanisms in major depressive disorder and are of relevance for response to antidepressive treatment. We performed proton magnetic resonance spectroscopy (1H-MRS) of the hippocampus at 3 T in 18 unmedicated subjects with unipolar major depressive episodes and in 10 age- and gender-matched healthy volunteers. Thirteen patients underwent a second examination after 8 wk treatment with either citalopram (n=7) or nortriptyline (n=6). Of these patients, 11 MRS datasets could be used for the assessment of treatment correlates. In the cross-sectional comparison, we observed a significant reduction of the metabolic ratios Glx/Cr (Glx=glutamine, glutamate and gamma-aminobutyric acid) and glutamine (Gln)/Cr in the patient group. The Gln/Glx ratio also showed a trend towards significant reduction. The individual effect of treatment correlated with an increase in the absolute concentrations of N-acetylaspartate (NAA) and of choline compounds (Cho). Low baseline NAA and Cho levels predicted positive treatment effects. There was no difference in any clinical or metabolic measure, either at baseline or at follow-up between the two treatment groups (citalopram, nortriptyline). Our data provide first evidence for a reduction of Gln in the hippocampus of subjects with major depression. Furthermore, we provide first evidence in patients with major depression for neurorestorative effects in the hippocampus by pharmacological treatment expressed by a correlation of NAA and Cho increases with treatment response. This accounts in particular for those patients with low NAA and Cho baseline levels.

Differential efficacy of escitalopram and nortriptyline on dimensional measures of depression

BACKGROUND

Tricyclic antidepressants and serotonin reuptake inhibitors are considered to be equally effective, but differences may have been obscured by internally inconsistent measurement scales and inefficient statistical analyses.

AIMS

To test the hypothesis that escitalopram and nortriptyline differ in their effects on observed mood, cognitive and neurovegetative symptoms of depression.

METHOD

In a multicentre part-randomised open-label design (the Genome Based Therapeutic Drugs for Depression (GENDEP) study) 811 adults with moderate to severe unipolar depression were allocated to flexible dosage escitalopram or nortriptyline for 12 weeks. The weekly Montgomery-Asberg Depression Rating Scale, Hamilton Rating Scale for Depression, and Beck Depression Inventory were scored both conventionally and in a more novel way according to dimensions of observed mood, cognitive symptoms and neurovegetative symptoms.

RESULTS

Mixed-effect linear regression showed no difference between escitalopram and nortriptyline on the three original scales, but symptom dimensions revealed drug-specific advantages. Observed mood and cognitive symptoms improved more with escitalopram than with nortriptyline. Neurovegetative symptoms improved more with nortriptyline than with escitalopram.

CONCLUSIONS

The three symptom dimensions provided sensitive descriptors of differential antidepressant response and enabled identification of drug-specific effects.

The phenomenology of recurrent brief depression with and without hypomanic features

BACKGROUND

The nosologic status of recurrent brief depression (RBD) is debated. We studied the phenomenology of RBD in a clinical sample of outpatients.

METHODS

Forty patients (mean age 33; 73% females) and 21 age- and gender-matched mentally healthy controls were examined (clinical interview, M.I.N.I. neuropsychiatric interview, MADRS, Stanley Foundation Network Entry Questionnaire). Exclusion criteria were bipolar I or II disorders, a history of psychosis, concurrent major depressive episode, organic brain or personality disorders (clusters A and B).

RESULTS

The mean age of onset of RBD was 20 years with a mean of 14 episodes/year with brief (mean 3 days) severe depressive episodes. Nineteen (47%) reported additional short episodes of brief hypomania (>1 day duration; RBD-H) of which nine (23%) never had experienced a major depression. Twenty-one (53%) patients reported RBD only (RBD-O) with or without (n=12) past history of major depression or dysthymia. During the last depressive episode, 76% of the RBD-O and 90% of the RBD-H patients had a melancholic depression. Seventy-one % of the RBD-O and 79% of the RBD-H reported at least two out of three atypical symptoms. Nineteen (48%) of the patients reported anger attacks and panic disorder, the latter being more prevalent in the RBD-H subgroup (68% versus 29%, p=0.012).

LIMITATIONS

Cross-sectional study of self-referrals or patients referred by primary care physicians or psychiatrists.

CONCLUSIONS

The study supports the validity of RBD as a disorder separate from bipolar II, cyclothymia and recurrent major depression. A brief episode of hypomanic symptoms is a severity marker of RBD.