Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices

Effects of esketamine on patient-reported outcomes in major depressive disorder with active suicidal ideation and intent: a pooled analysis of two randomized phase 3 trials (ASPIRE I and ASPIRE II)

PURPOSE

To assess the effect of esketamine nasal spray on patient-reported outcomes (PROs) in patients with major depressive disorder having active suicidal ideation with intent (MDSI).

METHODS

Patient-level data from two phase 3 studies (ASPIRE I; ASPIRE II) of esketamine + standard of care (SOC) in patients (aged 18-64 years) with MDSI, were pooled. PROs were evaluated from baseline through end of the double-blind treatment phase (day 25). Outcome assessments included: Beck Hopelessness Scale (BHS), Quality of Life (QoL) in Depression Scale (QLDS), European QoL Group-5-Dimension-5-Level (EQ-5D-5L), and 9-item Treatment Satisfaction Questionnaire for Medication (TSQM-9). Changes in BHS and QLDS scores (baseline to day 25) were analyzed using a mixed-effects model for repeated measures (MMRM).

RESULTS

Pooled data for esketamine + SOC (n = 226; mean age: 40.5 years, 59.3% females) and placebo + SOC (n = 225; mean age: 39.6 years, 62.2% females) were analyzed. Mean ± SD change from baseline to day 25, esketamine + SOC vs placebo + SOC (least-square mean difference [95% CI] based on MMRM): BHS total score, - 7.4 ± 6.7 vs - 6.8 ± 6.5 [- 1.0 (- 2.23, 0.21)]; QLDS score, - 14.4 ± 11.5 vs - 12.2 ± 10.8 [- 3.1 (- 5.21, - 1.02)]. Relative risk (95% CI) of reporting perceived problems (slight to extreme) in EQ-5D-5L dimensions (day 25) in esketamine + SOC vs placebo + SOC: mobility [0.78 (0.50, 1.20)], self-care [0.83 (0.55, 1.27)], usual activities [0.87 (0.72, 1.05)], pain/discomfort [0.85 (0.69, 1.04)], and anxiety/depression [0.90 (0.80, 1.00)]. Mean ± SD changes from baseline in esketamine + SOC vs placebo + SOC for health status index: 0.23 ± 0.21 vs 0.19 ± 0.22; and for EQ-Visual Analogue Scale: 24.0 ± 27.2 vs 19.3 ± 24.4. At day 25, mean ± SD in domains of TSQM-9 scores in esketamine + SOC vs placebo + SOC were: effectiveness, 67.2 ± 25.3 vs 56.2 ± 26.8; global satisfaction, 69.9 ± 25.2 vs 56.3 ± 27.8; and convenience, 74.0 ± 19.4 vs 75.4 ± 18.7.

CONCLUSION

These PRO data support the patient perspective of the effect associated with esketamine + SOC in improving health-related QoL in patients with MDSI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: ASPIRE I, NCT03039192 (Registration date: February 1, 2017); ASPIRE II, NCT03097133 (Registration date: March 31, 2017).

The Potential of Scopolamine as an Antidepressant in Major Depressive Disorder: A Systematic Review of Randomized Controlled Trials

Major depressive disorder is one of the most severe mental disorders. It strongly impairs daily functioning, and, in extreme cases, it can lead to suicide. Although different treatment options are available for patients with depression, there is an ongoing search for novel therapeutic agents, such as scopolamine (also known as hyoscine), that would offer higher efficacy, a more rapid onset of action, and a more favorable safety profile. The aim of our study was to review the current clinical evidence regarding the use of scopolamine, a promising therapeutic option in the treatment of depression. A systematic literature search was performed using PubMed, Embase, and CENTRAL databases up to 5 June 2023. We included randomized placebo-controlled or head-to-head clinical trials that compared the clinical efficacy and safety of scopolamine in the treatment of major depressive disorder. Two reviewers independently conducted the search and study selection and rated the risk of bias for each study. Four randomized controlled trials were identified in the systematic review. The included studies investigated the use of scopolamine administered as an oral, intramuscular, or intravenous drug, alone or in combination with other antidepressants. The results indicated that scopolamine exerts antidepressant effects of varying intensity. We show that not all studies confirmed a statistically and clinically significant reduction of depressive symptoms vs. placebo. A broader perspective on scopolamine use in antidepressant treatment should be confirmed in subsequent large randomized controlled trials assessing both effectiveness and safety. Therefore, studies directly comparing the effectiveness of scopolamine depending on the route of administration are required.

Efficacy and tolerability of desvenlafaxine in the real-world treatment of patients with major depression: a narrative review and an expert opinion paper

INTRODUCTION

Major depressive disorder (MDD) is a common severe mental disorder, requiring a tailored and integrated treatment. Several approaches are available including different classes of antidepressants various psychotherapeutic approaches, and psychosocial interventions. The treatment plan for each patient with MDD should be differentiated on the basis of several clinical, personal, and contextual factors.

AREAS COVERED

Desvenlafaxine - a serotonine-noradrenergic reuptake inhibitor (SNRI) antidepressant - has been approved in the United States in 2008 for the treatment of MDD in adults, and has been recently rediscovered by clinicians due to its good side-effect profile and its clinical effectiveness. A narrative review on efficacy, tolerability and use of desvenlafaxine in clinical practice was carried out. The keywords: 'major depression', 'depression,' 'desvenlafaxine,' 'efficacy,' 'clinical efficacy,' 'side effects', 'tolerability,' 'elderly patients', 'consultation-liaison', 'menopausal', 'young people', 'adolescent' were entered in PubMed, ISI Web of Knowledge, Scopus and Medline. No time limit was fixed, the search strategy was implemented on May 10, 2023.

EXPERT OPINION

Desvenlafaxine should be listed among the optimal treatment strategies for managing people with MDD, whose main strengths are: 1) ease of dosing; 2) favorable safety and tolerability profile, 3) absence of sexual dysfunctions, weight gain and low rate of discontinuation symptoms; 4) low risk of drug-drug interactions.

Time trade-off health state utility values for depression: a systematic review and meta-analysis

PURPOSE

This study aims to systematically review the literature on health utility in depression generated by time trade-off (TTO) method and to compare health state vignettes.

METHODS

Systematic literature search was conducted following PRISMA guideline in 2020 November (updated in 2022 March) in Pubmed, Web of Science, PsycInfo, and Cochrane Database of Systematic Reviews. Random effect meta-analysis was conducted to pool vignette-based utility values of mild, moderate, and severe depression and to compare the preferences of depressed and nondepressed population.

RESULTS

Overall, 264 records were found, 143 screened by title and abstract after removing duplicates, 18 assessed full text, and 14 original publications included. Majority of the studies (n = 9) used conventional TTO method, and most of the studies (n = 8) applied 10-year timeframe. Eight studies evaluated self-experienced health (own-current depression). Six studies assessed vignette-based health states of remitted, mild, moderate, and severe depression, half of them applied McSad measure based health description. Altogether, 61 different utility values have been cataloged, mean utility of self-experienced depression states (n = 33) ranged between 0.89 (current-own depression) and 0.24 (worst experienced depression). Pooled utility estimates for vignette-based mild, moderate, and severe depression was 0.75, 0.66 and 0.50, respectively. Meta-regression showed that severe depression (β = -0.16) and depressed sample populations (β =  -0.13) significantly decrease vignette-based utility scores.

CONCLUSION

Our review revealed extent heterogeneity both in TTO methodology and health state vignette development. Patient's perception of depression health states was worse than healthy respondents.

Health-related quality of life-based definition of remission from depression among primary care patients

Background

Depression undermines health-related quality of life (HRQoL). Remission is the central aim of all treatments for depression, but the degree of remission necessary for depressive patients' HRQoL to correspond to the normal range of the general population remains unknown.

Methods

The Vantaa Primary Care Depression Study prospectively followed-up a screening-based cohort of depressive primary care patients for 5 years. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was used to diagnose major depressive disorder. HRQoL was measured by the generic 15D instrument at baseline and at 5 years (N = 106, 77% of baseline patients), and compared with the 15D results of an age-standardized general population sample from the Finnish Health 2011 Survey (N = 4,157). Receiver operating characteristic analyses determined the optimal Hamilton Depression Rating Scale (HAMD), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) cut-offs for remission, using the 15D score as the construct validator. Remission was defined as the score at which HRQoL reached the general population range (minimum mean - 1 SD). As age may influence HRQoL, patients older and younger than the median 52 years were investigated separately.

Results

For HAMD, the optimal cut-off point score was 8.5, for BDI 10.5, and for BAI 11.5. The differences between the findings of the younger and older patients were small.

Limitations

Cross-sectional analysis, small number of patients in the cohort.

Conclusion

Depressive primary care patients' HRQoL reaches the normal variation range of the general population when their depression and anxiety scores reach the conventional clinical cut-offs for remission.

Outcomes of student trainee-delivered cognitive-behavioral therapy (CBT) on internalizing symptoms, CBT skills, and life satisfaction

Increased quality of life (QoL) is rated by patients as a primary factor in determining recovery from psychopathology. Cognitive-behavioral therapies (CBTs) are the most well-researched psychotherapies for internalizing disorders and appear effective at reducing symptoms even when delivered by trainees. Existing research suggests that the effects of CBTs on QoL are more modest than their effects on symptoms. However, little is known about the effects of trainee-delivered CBT on life satisfaction, a subjective measure of QoL. We analyzed data from 93 clients treated by students (n=23) in a graduate-level training clinic using an intent-to-treat approach, completers case analyses, and random forest imputation. Across methods of handling missing data, improvements in anxiety, depression, and CBT skills were more marked than improvements in QoL. Exploratory analyses suggested baseline life satisfaction was the strongest predictor of end-of-treatment life satisfaction. Future research should explore alternatives to "standard" CBT for clients with low life satisfaction.

A survey of depression and anxiety disorders in urban and rural Suriname

BACKGROUND

Suriname is a Low-middle income country consisting of diverse population groups. Epidemiological studies concerning mental disorders like depression and anxiety had not been conducted until 2015. The treatment gap for mental disorders in Low and middle-income countries (LMICs) may reach 76-80% as treatment is not always readily available. In this study, we estimate and compare the prevalence of potential cases of depression and anxiety, as well as the size of the treatment gap in a rural (Nickerie) and urban (Paramaribo) region of Suriname, a lower middle-income country.

METHODS

Subjects were selected by a specific sampling method of the national census bureau. The Center for Epidemiological Studies-Depression (CES-D) was used to assess depression. Generalized anxiety disorder was assessed with the Generalized Anxiety Disorder 7 (GAD-7) and The Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ) were used to assess Panic disorder. The treatment gap was calculated by estimating the percentage of subjects with depression or anxiety that did not seek out professional help.

RESULTS

About 18% of the respondents from Nickerie and 16% from Paramaribo were at risk of depression and the established cut-off values of the instruments used indicate that about 3-4% in both regions may suffer from Generalized Anxiety Disorder. Women in both samples were most at risk of high anxiety about body sensations and maladaptive thoughts about panic. The treatment gap varies between 78 and 100% for the two disorders.

CONCLUSIONS

A high depression rate has been found in both areas, especially among young females. In addition, a high treatment gap is noted which insinuates that more therapeutic strategies are required to tackle depression and anxiety in Suriname.

Depression, Anxiety, and Their Association to Health-Related Quality of Life in Men Commencing Prostate Cancer Treatment at Tertiary Hospitals in Cape Town, South Africa

Background

Comorbid depression and anxiety in men with localised prostate cancer (CaP) largely go undiagnosed and untreated and their effects on health-related quality of life (HRQOL) in men with CaP should not be underestimated. We examined the prevalence of depression and anxiety and its association with HRQOL in men about to commence treatment for CaP and the differences between treatment groups, radical prostatectomy (RP) and radiation therapy (RT).

Method

One hundred and seven participants from a longitudinal prospective observational study assessing depression, anxiety and HRQOL in men with localised CaP (DAHCaP), were used in this cross-sectional analysis. Data were collected shortly before participants were scheduled to receive their treatment. The Centre for Epidemiologic Studies Depression Scale (CES-D), the State Trait Anxiety Inventory (STAI), the Memorial Anxiety Scale for Prostate Cancer (MAX-PC), the European Organisation for Research and Treatment in Cancer Quality of Life questionnaire (EORTC QLQ-C30) and (EORTC QLQ-PR25) were used in this analysis.

Results

Symptoms of depression pre-treatment were noted in 39.3%, state anxiety 28%, trait anxiety 31.4% and prostate cancer anxiety in 12.1% of participants. Statistically significant correlations (P ≤ .05) with the CES-D and a cluster of symptoms on the EORTC QLQ-C30 domains for Global Health (r_s = −.35), fatigue (r_s = .38), pain (r_s = .32), dyspnoea (r_s = .28), insomnia (r_s = .30) and finance (r_s = .26) and EORTC QLQ-PR25 domains for urinary symptoms (r_s = .43), bowel (r_s = .43) and hormone replacement therapy (HRT) (r_s = .41) were observed.

Statistically significant correlations were also noted between the STAI-S and EORTC QLQ-C30 and EORTC QLQ-PR25. No statistically significant difference was noted between treatments.

Conclusion

More men were depressed than anxious with significant associations with HRQOL prior to commencement of treatment. CaP treatments should focus not only on the prevailing indisposition but include a psychooncological and HRQOL assessment at pre-treatment in high-risk individuals.

Efficacy and safety of tipepidine as adjunctive therapy in major depressive disorder: A randomized, double-blind, placebo-controlled clinical trial

AIM

Tipepidine, a synthetic, non-opioid expectorant, has been shown to improve depressive-like behavior in animal models of depression. In this study, we assessed the efficacy and tolerability of tipepidine combination therapy with citalopram in treatment of major depressive disorder (MDD).

METHODS

In a randomized, double-blinded, placebo-controlled clinical trial, 62 patients with MDD were assigned into two parallel groups to receive citalopram (up to 40 mg/day) plus placebo or citalopram plus tipepidine (30 mg twice daily) for 6 weeks. Participants were assessed with the Hamilton Rating Scale for Depression (HAM-D) at baseline and Weeks 2, 4, and 6.

RESULTS

Fifty-six patients completed the trial. The tipepidine group showed greater improvement in HAM-D scores from baseline to all three study time points (P = 0.048 for all). The remission and response-to-treatment rates were significantly higher in the tipepidine group (53.6% and 100%) compared to the placebo group (25.0% and 75%) at the study end-point (P = 0.029 and 0.005, respectively). The remission and response times in patients in the tipepidine group were also shorter compared with the placebo group (log-rank P = 0.020 and 0.004). There was no significant difference between the two groups in baseline parameters or frequency of side-effects.

CONCLUSION

Tipepidine combination therapy with citalopram can effectively improve symptoms of patients with MDD in a shorter period of treatment. However, further studies with larger sample sizes and longer follow-up treatment are needed to confirm our findings.

Perceived burden of illness in patients entering for treatment in a university hospital – is the threshold to secondary care higher for patients with depression than for those with somatic disorders?

Background

The threshold to secondary health care should be similar for all patients independent of the underlying disease. This study compared, using a validated health-related quality of life (HRQoL)-instrument, whether the perceived burden of illness is similar in patients admitted for secondary care treatment into a university hospital because of one of six common conditions.

Methods

HRQoL, assessed by the generic 15D instrument before elective treatment, was compared in six groups: operative treatment of cataract (n = 219), operative treatment of cervical or lumbar radicular pain (n = 270), hysterectomy due to benign uterine conditions (n = 337), hip or knee replacement surgery (n = 223), coronary angiography due to suspected coronary artery disease (n = 261), and secondary care treatment of depression (n = 89).

Results

Mean (±SD) HRQoL score was clearly highest in patients with benign uterine conditions (0.908 ± 0.071) and lowest in patients with depression (0.729 ± 0.120) (P < 0.001 between the groups). Also all the other groups had a significantly (P < 0.001) higher baseline HRQoL score (ranging from 0.802 to 0.824) than patients with depression. Outcome of treatment, in terms of HRQoL improvement, was in depressive patients at least equal, and in some cases even better, than that in the other groups.

Discussion

Our results imply that, at least concerning perceived burden of illness, patients with depression are worse off when admitted to secondary care treatment than patients with many somatic conditions. That may be a consequence of poor motivation of depressive patients to seek treatment or that, contradictory to guidelines, the health care system does nor give priority to those worst off and sets a higher threshold for specialized care of patients with depression than of those with common somatic disorders.

A 5-year prospective study of predictors for functional and work disability among primary care patients with depressive disorders

Objective:

To study prevalence of and predictors for functional and work disability among primary care (PC) patients with depressive disorders in prospective long-term follow-up.

Methods:

The Vantaa Primary Care Depression Study followed up prospectively 137 patients with depressive disorders for 5 years with a life chart. Information on level of functioning in general and in different dimensions, employment, sick leaves and disability pensions were obtained from interviews and patient records.

Results:

Level of functioning and work ability were strongly associated with time spent depressed and/or current severity of depression. Patients who belonged to the labour force at baseline spent one-third of the follow-up off work due to depression; two-thirds were granted sick leaves, and one-tenth a disability pension due to depression. Longer duration of depression, co-morbid disorders and having received social assistance predicted dropping out from work.

Conclusion:

Duration of depressive episodes appears decisive for long-term disability among PC patients with depression. Patients spent one-third of the follow-up off work due to depression, and remaining outside the labour force is a common outcome. Psychiatric and somatic co-morbidities, education and socio-economic means influence the level of functioning and ability to work, but are not equally important for all areas of life.

Health-related quality of life of primary care patients with depressive disorders

Background

Depressive disorders are known to impair health-related quality of life (HRQoL) both in the short and long term. However, the determinants of long-term HRQoL outcomes in primary care patients with depressive disorders remain unclear.

Methods

In a primary care cohort study of patients with depressive disorders, 82% of 137 patients were prospectively followed up for five years. Psychiatric disorders were diagnosed with SCID-I/P and SCID-II interviews; clinical, psychosocial and socio-economic factors were investigated by rating scales and questionnaires plus medical and psychiatric records. HRQoL was measured with the generic 15D instrument at baseline and five years, and compared with an age-standardized general population sample (n = 3707) at five years.

Results

Depression affected the 15D total score and almost all dimensions at both time points. At the end of follow-up, HRQoL of patients in major depressive episode (MDE) was particularly low, and the association between severity of depression (Beck Depression Inventory [BDI]) and HRQoL was very strong (r = −0.804). The most significant predictors for change in HRQoL were changes in BDI and Beck Anxiety Inventory (BAI) scores. The mean 15D score of depressive primary care patients at five years was much worse than in the age-standardized general population, reaching normal range only among patients who were in clinical remission and had virtually no symptoms.

Conclusions

Among depressive primary care patients, presence of current depressive symptoms markedly reduces HRQoL, with symptoms of concurrent anxiety also having a marked impact. For HRQoL to normalize, current depressive and anxiety symptoms must be virtually absent.

The beneficial effects of Qigong on elderly depression

Health Qigong, especially the Eight-Section Brocades (or Baduanjin), has been well established as an effective adjunct intervention to alleviate depressive symptoms of older adults. The easy to learn and safe format of health Qigong allows the promotion and employment by health care professionals to improve the physical and psychosocial wellness of older adults. The cultural relevance of Qigong practice enhances its popularity as a health maintenance practice in Chinese community. In general, the antidepressive effects of Qigong are put forward through psychosocial, physiological, and neurobiological mechanisms. More specific, the beneficial effects of Qigong can be further substantiated by findings of several research studies.

The association between antidepressant use and deaths from road traffic accidents: a case-crossover study

PURPOSE

Antidepressants are some of the most commonly used psychiatric medications, but little information is available about the effects of antidepressant treatment on the risk of traffic accidents across classes of antidepressants or associated with each substance individually. To investigate the relationship between exposure to antidepressants and risk of fatality in road traffic accidents.

METHODS

We used a Korean national road traffic authority database linked with a national health insurance database between January 1, 2010 and December 31, 2014 and applied a case-crossover design. The study subjects were drivers in South Korea who died from traffic accidents and who had prescriptions for antidepressants within 1 year prior to the date of the accident. We compared the status of prescription for antidepressants with the hazard period and four matched control periods using conditional logistic regression, adjusting for other drug use. The trends of antidepressant utilization were described in terms of the number of prescriptions. A case-case-time-control design was applied to drugs with an increasing trend in use and a significant case-crossover odds ratio (OR).

RESULTS

A total of 1250 antidepressant-using drivers were included, and an increased risk was observed during the 30-day hazard period (adjusted OR 1.30; 95% CI 1.03-1.63). Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) showed significant risks, but tricyclic antidepressants did not. However, the associations of all antidepressants, SSRIs, SNRIs, escitalopram, and duloxetine did not remain significant after adjusting for trends in utilization. Paroxetine and milnacipran were associated with increased risks, with no obvious increase in their utilization, but the possibility of confounding by indication could have affected the results for milnacipran.

CONCLUSION

Considering the trends of antidepressant prescription and utilization, the use of paroxetine increased the risk of fatal traffic accidents.

Validation of the Mental Health Continuum-Short Form and the dual continua model of well-being and psychopathology in an adult mental health setting

OBJECTIVE

The growing evidence for the dual continua model of psychopathology and well-being has important implications for measuring outcomes in mental health care. The aim of the current study is to validate a measure of well-being as well as the dual continua model in adults with mood, anxiety, personality, and developmental disorders.

METHODS

472 adult psychiatric outpatients filled out the Mental Health Continuum-Short Form (MHC-SF) and the Outcome Questionnaire before start of treatment.

RESULTS

Confirmatory factor analyses (CFA) confirmed the three-factor structure of emotional, psychological, and social well-being of the MHC-SF. The dual continua model had the best fit in the complete sample and the different diagnostic groups.

CONCLUSION

The MHC-SF is a reliable and valid instrument to measure well-being in the psychiatric population. Although relatively high correlations between psychopathology and well-being exist, the results underline the importance to measure well-being in addition to psychopathology in mental health care.

The association between different domains of quality of life and symptoms in primary care patients with emotional disorders

Despite the importance of quality of life (QoL) in primary care patients with emotional disorders, the specific influence of the symptoms of these disorders and the sociodemographic characteristics of patients on the various QoL domains has received scant attention. The aim of the present study of primary care patients with emotional disorders was to analyse the associations between four different QoL domains and the most prevalent clinical symptoms (i.e., depression, anxiety and somatization), while controlling for sociodemographic variables. A total of 1241 participants from 28 primary care centres in Spain were assessed with the following instruments: the Patient Health Questionnaire (PHQ)-9 to evaluate depression; the Generalized Anxiety Disorder Scale (GAD)-7 for anxiety; PHQ-15 for somatization; and the World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) to assess four broad QoL domains: physical health, psychological health, social relationships, and environment. The associations between the symptoms and QoL domains were examined using hierarchical regression analyses. Adjusted QoL mean values as a function of the number of overlapping diagnoses were calculated. The contribution of sociodemographic variables to most QoL domains was modest, explaining anywhere from 2% to 11% of the variance. However, adding the clinical variables increased the variance explained by 12% to 40% depending on the specific QoL domain. Depression was the strongest predictor for all domains. The number of overlapping diagnoses adversely affected all QoL domains, with each additional diagnosis reducing the main QoL subscales by 5 to 10 points. In primary care patients with a diagnostic impression of an emotional disorders as identified by their treating GP, clinical symptoms explained more of the variance in QoL than sociodemographic factors such as age, sex, level of education, marital status, work status, and income. Given the strong relationship between depressive symptoms and QoL, treatment of depression may constitute a key therapeutic target to improve QoL in people with emotional disorders in primary care.

Case-mix tool, costs and effectiveness in improving primary care mental health and substance abuse services

BACKGROUND

Despite its importance in improving care and developing services, high-quality data evaluating cost-effectiveness and services in different case-mix populations is scarce in primary care.

AIMS

The objective was to investigate the service use of those mental health and substance abuse patients, who use lots of services.

METHODS

Primary health care diagnosis-related groups (pDRG) is a tool to evaluate service provider system and improve efficiency, productivity and quality. We viewed all pDRG results available from the year 2015 concerning municipal mental health and substance abuse services.

RESULTS

In primary care mental health and substance abuse services, the most common ICD-10-codes were depression and substance abuse. One-fifth of patients produced 57% of costs. Their medium of appointments was 16 per year versus 6 per year of all patients. Only 54% of their diagnoses were recorded in the electronic health records versus 75% of all patients. They made 5.7 different pDRG episodes, including 1.8 episodes of depression, per patient. The average episode cost for this patient group was 301€.

CONCLUSIONS

pDRG makes health care production transparent also in mental health and substance abuse services. It is easy to identify patients, who use a lot of services and thus induce the majority of costs, and focus on their needs in managing and developing services.

Electronic cigarette use among individuals with a self-reported eating disorder diagnosis

OBJECTIVE

The primary study aim was to examine whether rates of using e-cigarettes ("vaping") to lose weight are elevated among American adults who self-report having an eating disorder (ED).

METHOD

Adult vapers who reported either currently having an ED (n = 178; 72.5% women, 83.7% White, mean age 33.26 [SD = 8.35] years) or no ED history (n = 433; 54.7% women, 83.4% White, 35.98 [SD = 11.71] years) completed an anonymous survey.

RESULTS

Relative to participants reporting no ED history, participants who reported currently having an ED were more likely to report vaping to lose/control weight, because it can be concealed from others, and due to the availability of sweet flavors. Participants reporting a current ED also were more likely to vape daily, to use higher nicotine concentrations, and to vape to relieve negative affect than were individuals without EDs.

DISCUSSION

Individuals who self-reported currently having an ED endorsed vaping motives that are consistent with eating pathology (e.g., substance-induced weight loss, hiding compensatory behaviors from others). They also were more likely to vape daily and to use higher nicotine concentrations, raising health concerns. The findings suggest that treatment providers should screen for e-cigarette use in clients seeking ED treatment.

Surviving Depression: Clinical Qualitative Analysis of Long-Term Survival for Ethnically Diverse, Depressed Patients

Depression is persistent and recurrent across ethnic groups. Few narrative analyses of long-term outcomes for ethnically diverse adults with depression exist. We combined 9 years of quantitative data, qualitative interviews at 10 years, clinician ratings of outcomes, and a community discussion group with the objective of describing long-term recovery and survival of diverse primary care patients after an episode of depression. Nearly half of participants were found to be depressed at some time over a 10-year period, and most cases across ethnic groups were judged to need further treatment. The ethnically diverse community members that analyzed the transcripts emphasized assets that participants showed in surviving multiple life stresses. Different sex and ethnic/racial groups had different characteristics of engaging in care, with Latino women in particular raising concerns about care engagement, coping with stress, and long-term outcomes.

Factors Related to the Changes in Quality of Life for Patients With Depression After an Acute Course of Electroconvulsive Therapy

OBJECTIVE

The aim of this study was to examine the effect of electroconvulsive therapy (ECT) on quality of life (QOL), depressive symptoms, and functioning for patients with depression, and to explore the variables related to QOL changes.

METHODS

Ninety-five inpatients with depression receiving at least 6 ECT sessions and completed all measures were included. Quality of life, symptom severity, and functioning were assessed using Short Form 36 (SF-36), the 17-item Hamilton Rating Scale for Depression (HAMD-17), and the Modified Work and Social Adjustment Scale (MWSAS), before and after ECT. The SF-36 includes 8 subscales, physical component summary (PCS), and mental component summary (MCS). Adverse effects after ECT, including headache, muscle pain, and nausea/vomiting, were also recorded.

RESULTS

All 8 SF-36 subscales, PCS, MCS, HAMD-17, and MWSAS improved significantly after treatment. Using multiple linear regression analysis, MWSAS changes predicted PCS changes significantly after adjusting for baseline PCS. Similarly, using multiple linear regression analysis, MWSAS changes were significant variables associated with MCS changes after adjusting for ECT frequency, HAMD-17 changes, and baseline MCS. The ECT improved QOL, depressive symptoms, and functioning.

CONCLUSIONS

Whether strategies to enhance functioning during an acute course of ECT could improve QOL is needed to be examined in a further study.

Daily activity level improvement with antidepressant medications predicts long-term clinical outcomes in outpatients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) significantly impacts performance of both work- and nonwork-related routine daily activities. We have shown that work productivity is significantly impaired in employed MDD patients, but the extent of impairments in nonwork-related routine activities and its association with antidepressant treatment outcomes has not been established.

MATERIALS AND METHODS

Activity impairment was measured using the sixth item of Work Productivity and Activity Impairment Scale in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial (n=665). Published norms were used to define activity impairment levels. The relationship between activity impairment and baseline sociodemographic and clinical characteristics was evaluated along with changes in activity impairment and its relationship with other clinical outcomes such as symptom severity, function, and side effect burden. Remission status at 3 and 7 months was predicted based on week 6 activity impairment level.

RESULTS

Higher psychosocial and cognitive impairments and greater number of comorbid medical conditions were associated with greater activity impairment at baseline. Proportion of participants with severe activity impairment declined from 47.6% at baseline to 18.7% at 3 months, while mean activity impairment decreased from 57.1 at baseline to 32.8 at 3 months. During course of treatment, levels of activity impairment correlated most strongly with psychosocial function among measures of symptom severity, function, quality of life, and side effect burden. No or minimal activity impairment at week 6 was associated with two to three times higher rates of remission at 3 and 7 months as compared to moderate or severe activity impairment levels even after controlling for remission status at week 6 and select baseline variables.

CONCLUSION

Depressed patients have high levels of nonwork-related activity impairment at baseline that improves significantly with treatment and independently predicts long-term clinical outcomes. Brief systematic assessment of activity impairment during the course of antidepressant treatment can help inform clinical decision-making.

Depression, Disability, and Rehabilitation Services for Women

The purpose of this paper is to review scientific evidence for the co-occurrence of major depressive illness and disability, and to examine this phenomenon specifically for women in the United States today. Following a discussion of different ways of operationalizing the concept of disability, the analysis addresses gender biases in disability measurement as well as in recent research on depression and functional impairment. Next, the results of research regarding co-occurrence of disability and depression are reviewed, highlighting those studies focused specifically on women. Turning to research on rehabilitation services for those with psychiatric disabilities, studies suggest that service delivery models fail to address needs specific to women with mental illness in general, as well as those women experiencing severe depression. Thus, the analysis concludes with a series of suggestions and future directions for investigators seeking to better understand the linkages between depression, disability, and rehabilitation services for women.

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity

BACKGROUND

Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

METHODS

In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

RESULTS

The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

LIMITATIONS

Moderate sample size. Data collected in 2002-2004.

CONCLUSIONS

The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.

IMPROVEMENTS IN PSYCHOSOCIAL FUNCTIONING AND HEALTH-RELATED QUALITY OF LIFE FOLLOWING EXERCISE AUGMENTATION IN PATIENTS WITH TREATMENT RESPONSE BUT NONREMITTED MAJOR DEPRESSIVE DISORDER: RESULTS FROM THE TREAD STUDY

BACKGROUND

Functional impairments often remain despite symptomatic improvement with antidepressant treatment, supporting the need for novel treatment approaches. The present study examined the extent to which exercise augmentation improved several domains of psychosocial functioning and quality of life (QoL) among depressed participants.

METHODS

Data were collected from 122 partial responders to antidepressant medication. Participants were randomized to either high- (16 kcal/kg of weight/week [KKW]) or low-dose (4-KKW) exercise. Participants completed a combination of supervised and home-based exercise for 12 weeks. The Short-Form Health Survey, Work and Social Adjustment Scale, Social Adjustment Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, and Satisfaction with Life Scale were collected at 6 and 12 weeks. Participants with data for at least one of the two follow-up time points (n = 106) were analyzed using a linear mixed model to assess change from baseline within groups and the difference between groups for each psychosocial outcome measure. All analyses controlled for covariates, including baseline depressive symptomatology.

RESULTS

Participants experienced significant improvements in functioning across tested domains, and generally fell within a healthy range of functioning on all measures at Weeks 6 and 12. Although no differences were found between exercise groups, improvements were observed across a variety of psychosocial and QoL domains, even in the low-dose exercise group.

CONCLUSIONS

These findings support exercise augmentation of antidepressant treatment as a viable intervention for treatment-resistant depression to improve function in addition to symptoms.

Trajectory and predictors of quality of life in first episode psychotic mania

BACKGROUND

Little is known about the trajectory of quality of life (QoL) following a first episode of psychotic mania in bipolar disorder (BD). This 18-month longitudinal study investigated the trajectory of QoL, and the influence of premorbid adjustment and symptoms on 18-month QoL in a cohort of young people experiencing a first episode of psychotic mania.

METHODS

As part of an overarching clinical trial, at baseline, sixty participants presenting with a first episode of psychotic mania (BD Type 1 - DSM-IV) completed symptomatic and functional assessments in addition to the Premorbid Adjustment Scale - General Subscale. Symptom measures were repeated at 18-month follow up. QoL was rated using the Quality of Life Scale (QLS) at designated time points.

RESULTS

Mean QLS scores at initial measurement (8 weeks) were 61% of the maximum possible score, increasing significantly to 70% at 12 months, and 71.2% at 18-month follow-up. Premorbid adjustment and 18-month depressive symptoms were significantly associated with QoL at 18-month follow-up.

LIMITATIONS

Study limitations include the small sample size, inclusion of participants with psychotic mania only, use of measures originally designed for use with schizophrenia spectrum disorders, and lack of premorbid or baseline measurement of QoL.

CONCLUSIONS

Results suggest that QoL can be maintained early in BD, and reinforce the importance of assertively treating depressive symptoms throughout the course of this disorder. The emergence of a link between premorbid adjustment and poorer QoL in this cohort highlights the importance of assessing facets of adjustment when planning psychological interventions.

Depression Quality of Care: Measuring Quality over Time Using VA Electronic Medical Record Data

BACKGROUND

The Veterans Health Administration (VA) has invested substantially in evidence-based mental health care. Yet no electronic performance measures for assessing the level at which the population of Veterans with depression receive appropriate care have proven robust enough to support rigorous evaluation of the VA's depression initiatives.

OBJECTIVE

Our objectives were to develop prototype longitudinal electronic population-based measures of depression care quality, validate the measures using expert panel judgment by VA and non-VA experts, and examine detection, follow-up and treatment rates over a decade (2000-2010). We describe our development methodology and the challenges to creating measures that capture the longitudinal course of clinical care from detection to treatment.

DESIGN AND PARTICIPANTS

Data come from the National Patient Care Database and Pharmacy Benefits Management Database for primary care patients from 1999 to 2011, from nine Veteran Integrated Service Networks.

MEASURES

We developed four population-based quality metrics for depression care that incorporate a 6-month look back and 1-year follow-up: detection of a new episode of depression, 84 and 180 day follow-up, and minimum appropriate treatment 1-year post detection. Expert panel techniques were used to evaluate the measure development methodology and results. Key challenges to creating valid longitudinal measures are discussed.

KEY RESULTS

Over the decade, the rates for detection of new episodes of depression remained stable at 7-8 %. Follow-up at 84 and 180 days were 37 % and 45 % in 2000 and increased to 56 % and 63 % by 2010. Minimum appropriate treatment remained relatively stable over the decade (82-84 %).

CONCLUSIONS

The development of valid longitudinal, population-based quality measures for depression care is a complex process with numerous challenges. If the full spectrum of care from detection to follow-up and treatment is not captured, performance measures could actually mask the clinical areas in need of quality improvement efforts.

Valuation of depression co-occurring with a somatic condition: feasibility of the time trade-off task

BACKGROUND

Health state valuations obtained from the general population are used for cost-utility analyses of health-care interventions. Currently, most studies have focused on valuations of somatic conditions, to a much lesser extent of mental states, that is, depression and even less on valuations of depression co-occurring with somatic conditions.

OBJECTIVE

We tested the feasibility of the time trade-off (TTO) task to elicit valuations for depression solitary or co-occurring with a somatic condition. Moreover, we explored person- and state-related factors that may affect valuations.

DESIGN

During semi-structured interviews, 10 individuals (five women, mean age: 36 years) used a TTO task to value vignettes describing mild and severe depression; and mild depression co-occurring with moderate and severe states of cancer, diabetes or heart disease. During valuations, participants were thinking aloud. Feasibility criteria were successful completion and difficulty/concentration (1-10); logical consistency of values; and comprehension of the TTO, based on qualitative analysis of think aloud data. Factors influencing valuations were generated from think aloud data.

RESULTS

Participants reported satisfactory levels of difficulty (mean: 1.9) and concentration (mean: 8.3) and assigned consistent values. Qualitative analysis revealed difficulties with imagining: living with depression for lifetime (n = 4); reaching the age of 80 (n = 6); and living with a somatic condition and mentally healthy (n = 6). Person- and state-related factors, for example perceived susceptibility to depression (n = 4), appeared to affect valuations.

CONCLUSION

Quantitative findings supported feasibility of the valuation protocol, yet qualitative findings indicated that certain task aspects should be readdressed. Factors influencing valuations can be explored to better understand valuations.

Using the Knowledge Base of Health Services Research to Redefine Health Care Systems

This Perspective discusses 12 key facts derived from 50 years of health services research and argues that this knowledge base can stimulate innovative thinking about how to make health care systems safer, more efficient, more cost effective, and more patient centered, even as they respond to the needs of diverse communities.

Effects of religiosity and spirituality on the treatment response in patients with depressive disorders

BACKGROUND

Few studies have investigated the roles of religiosity and spirituality in predicting treatment response among psychiatric patients with depressive disorders.

METHODS

In total, 232 outpatients with depressive disorders completed measurements of psychological symptoms, religiosity, and spirituality at baseline. A response was defined as Clinical Global Impression-Improvement scale (CGI-I) score of 1 or 2 at the last visit during a 6-month treatment period. Univariate analyses and logistic regression analysis were used to identify predictors of treatment response.

RESULTS

In univariate analyses, treatment response was associated with marital status, longer treatment duration, less severe baseline symptoms, higher personal importance of religion, and higher spirituality. In logistic regression analysis, subjective important considerations for religion and spirituality were significantly related with treatment response after controlling for marital status, treatment duration, and baseline symptom severity. Of these variables, spirituality remained a significant predictor in the final model.

CONCLUSIONS

These findings suggest that higher spirituality may independently contribute to favorable treatment responses among depressed patients in addition to other demographic and clinical factors.

Measurement and comparison of health utility assessments in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common condition encountered in primary care medicine and is estimated to affect 12.5% of the United States population. This study aims to compare methods of assessing health utility in CRS.

METHODS

A cross-sectional sample of CRS patients (n = 137) were interviewed using direct health utility assessment measures: the visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). General quality of life (QOL) scores were obtained via the 36-item Short Form Health Survey (SF-36) and converted to SF-6D health utility values using a Bayesian algorithm. Disease-specific QOL was measured with the 22-item Sino-Nasal Outcome Test (SNOT-22). A selected subgroup of patients (n = 51) not initiating surgery or new treatment for CRS were re-interviewed within 3 weeks.

RESULTS

The mean ± SD health utilities were VAS 0.69 ± 0.19; TTO 0.80 ± 0.27; SG 0.93 ± 0.11; and SF-6D 0.72 ± 0.12; they differed significantly (p < 0.001). Only VAS scores differed based on disease state classification or the presence of nasal polyposis. Correlations between methods of determining health utility were weak, but significant. VAS, TTO, and SF-6D scores were significantly associated with SNOT-22 (p < 0.001 for all); however, SG and SNOT-22 were poorly correlated (Spearman correlation = -0.33). The test-retest reliability of TTO (Spearman correlation = 0.71) and SG (0.73) was strong.

CONCLUSION

CRS patients show significant impairment in QOL, with health utility values similar to those of patients with acquired immune deficiency syndrome (AIDS) or intermittent claudication using similar methods. The method of ascertainment significantly affects measured health utility, but the degree of impairment warrants improved recognition and appropriate treatment of the condition.

An implementation evaluation of the community engagement and planning intervention in the CPIC Depression Care Improvement Trial

The goal of this paper is to document and evaluate the process of implementing an evidence-based depression intervention in community settings through the use of community-academic partnered approaches. We discuss how and to what extent the goals of community engagement and collaborative planning were achieved in the intervention arm of the Community Partners in Care study that aimed to adapt evidence-based depression care toolkits for diverse agencies in Hollywood and South Los Angeles. We find that partnered research strategies have a potential to effectively engage community members around depression and involve them in intervention planning activities. Our results suggest that successful collaboration among diverse agencies requires that they understand what is expected of them, are comfortable with the role they choose to perform, and have organizational support to contribute to the project. To facilitate the development of collaborative relationships, time and effort should be devoted to explaining how collaboration among diverse agencies may take place.

Anxiety, depression, stress, and cortisol levels in mothers of children undergoing maintenance therapy for childhood acute lymphoblastic leukemia

The purpose of this study was to compare anxiety, depression, and stress between mothers of children during maintenance treatment for acute lymphoblastic leukemia (ALL) and matched controls. Twenty-six mothers were recruited from the hematology unit at a children's hospital, and 26 mothers were recruited from the community. Participants were matched to their child's age and gender. Mothers completed the Hospital Anxiety and Depression Scale, the Perceived Stress Sale, and collected salivary cortisol 4 times a day for 3 consecutive days. Compared with mothers of healthy children, anxiety scores did not differ (P=.10), but depression scores were higher (P=.003) in mothers of children with ALL. More mothers in the ALL group scored above the cutoff of 7 indicating clinical anxiety (46%) and depressive symptoms (27%). A trend toward increased stress was found in mothers in the ALL group. No difference was found in overall daily cortisol (area under the curve), daily decrease in cortisol (slope), and cortisol awakening response. Mothers of children with ALL experienced emotional symptoms many months after the initial diagnosis.

Quality of Life in Depressed Patients in UK Primary Care: The FINDER Study

OBJECTIVES

To investigate the impact of depression and its treatment on health-related quality of life (HRQoL) in a naturalistic, primary care setting in the UK.

METHODS

The Factors Influencing Depression Endpoints Research (FINDER) study was a European, 6-month, prospective, observational study designed to estimate HRQoL in patients with a clinical diagnosis of depression. This paper examines primary care patients recruited in the UK. HRQoL was measured at baseline and at 3 and 6 months after starting antidepressant therapy using the Short Form 36 Health Status Survey and the European Quality of Life-5 Dimensions (EQ-5D). Regression analysis was used to identify baseline and treatment variables independently and significantly associated with HRQoL. Further analyses included the effect of caseness for depression on HRQoL, the effect of moderate/severe pain at baseline on HRQoL, changes in overall pain, pain interference scores, and the use of different antidepressants by pain cohort.

RESULTS

A total of 608 patients was recruited from 58 centres and mean HRQoL was significantly below reported population norms at baseline. Most improvement in HRQoL was seen at 3 months for EQ-5D, with small additional improvement at 6 months. Worse HRQoL outcomes at 6 months were associated with higher somatic symptoms score, duration of depression at baseline, and switching within antidepressant classes. Patients meeting the criteria for caseness for depression, or with significant pain at baseline showed less improvement in HRQoL scores at 6 months.

CONCLUSION

Patients presenting with depression in primary care show reduced HRQoL compared to population norms. HRQoL improves during antidepressant treatment particularly within the first 3 months. Nonpainful somatic symptoms, socioeconomic factors, depression variables and switching within antidepressant class predict poor HRQoL outcome. Pain is a common symptom in depressed patients and remains after 6 months' treatment. Pain and somatic symptoms should be assessed in all patients with depression in primary care.

Health-related quality of life and symptom severity in Chinese patients with major depressive disorder

INTRODUCTION

Patients suffering from major depressive disorder (MDD) have been reported to have substantial long-lasting limitations in multiple domains of health-related quality of life (HRQoL). The thoughtful assessment of HRQoL and the impact of treatment response on HRQoL are emerging as important issues in the care of patients with major depressive disorder.

METHODS

One hundred and three patients meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for MDD took fluoxetine (20 mg/d) for 6 weeks and were assessed by the Short Form 36 Health Survey (SF-36), the 17-item Hamilton Depression Rating (HAMD-17) and the Clinical Global Impression (CGI) scales. Relationships between SF-36 scores and depressive symptom severity and early change of these symptoms were tested.

RESULTS

SF-36 component scores at week 6 were higher than those at baseline (all P ≤ 0.0058). Scores for general health were significantly higher in responders than non-responders (P = 0.0009). The overall HAMD-17 and CGI scores at 2- and 6-week follow-up were significantly lower than those at baseline (P ≤ 0.0001). Higher scores for anxiety/somatization were significantly associated with poorer SF-36 scores at baseline (P = 0.0001); role-physical scores at week 6 were positively correlated with reduction rate of anxiety/somatization in 2-week follow-up (P = 0.0002).

DISCUSSION

Depressive symptom severity was associated with HRQoL in patients with MDD. HRQoL may vary with severity of depression and/or anxiety-somatization at baseline.

Effectiveness of a psycho-educational group program for major depression in primary care: a randomized controlled trial

BACKGROUND

Studies show the effectiveness of group psychoeducation in reducing symptoms in people with depression. However, few controlled studies that have included aspects of personal care and healthy lifestyle (diet, physical exercise, sleep) together with cognitive-behavioral techniques in psychoeducation are proven to be effective.The objective of this study is to assess the effectiveness of a psychoeducational program, which includes aspects of personal care and healthy lifestyle, in patients with mild/moderate depression symptoms in Primary Care (PC).

METHODS

In a randomized, controlled trial, 246 participants over 20 years old with ICD-10 major depression were recruited through nurses/general practitioners at 12 urban Primary Care Centers (PCCs) in Barcelona. The intervention group (IG) (n=119) received a group psychoeducational program (12 weekly, 1.5 h sessions led by two nurses) and the control group (CG) (n=112) received usual care. Patients were assessed at baseline and at, 3, 6 and 9 months. The main outcome measures were the BDI, EQ-5D and remission based upon the BDI.

RESULTS

231 randomized patients were included, of whom 85 had mild depression and 146 moderate depression. The analyses showed significant differences between groups in relation to remission of symptoms, especially in the mild depression group with a high rate of 57% (p=0.009) at post-treatment and 65% (p=0.006) at 9 month follow up, and only showed significant differences on the BDI at post-treatment (p=0.016; effect size Cohen's d'=.51) and at 6 and 9 month follow-up (p= 0.048; d'=.44).In the overall and moderate sample, the analyses only showed significant differences between groups on the BDI at post-treatment, p=0.02 (d'=.29) and p=0.010 (d'=.47), respectively.The psychoeducation group improved significantly on the EQ-5D at short and long-term.

CONCLUSIONS

This psychoeducational intervention is a short and long-term effective treatment for patients with mild depression symptoms. It results in a high remission rate, is recommended in PC and can be carried out by nurses with previous training. In moderate patients, group psychoeducation is effective in the short-term.

TRIAL REGISTRATION

Clinical Trials.gov identifier NCT00841737.

[Results of the French cohort of the European observational study FINDER: quality of life of patients treated with antidepressants]

OBJECTIVES

To describe health-related quality of life (HRQoL), pain, clinical outcomes and treatment patterns in French patients with depression treated by general practitioners and psychiatrists.

METHODS

Factors Influencing Depression Endpoints Research (FINDER) is a European longitudinal observational, naturalistic, multicentre study to determine the HRQoL (SF-36 and EQ-5D) and to assess outcomes of depression and anxiety (Hospital Anxiety and Depression Scale [HADS]), and pain (VAS) in a population of depressed patients initiating antidepressant treatment. Clinical diagnosis of depression was based on physician's clinical judgment. Physicians decided at their own discretion and clinical practice to initiate pharmacological treatment for depression. Adult patients with a first or new episode of depression were enrolled between May 2004 and September 2005, and followed up for 6 months. Across Europe, 437 physicians observed 3468 patients.

RESULTS

In France, 606 patients (approximately 17% of the whole sample) were enrolled by 57 psychiatrists and 46 general practitioners. These patients were (mean ± SD) 45.6 ± 13.0 years old, 69% female and 39% having had a previous depressive episode in the last 2 years. According to the patient-rated HADS score greater or equal to 11, most patients (75%) were classified as cases of depression as well as cases of anxiety (84%); 51% of patients rated their overall pain severity (based on VAS cut-off of 30 mm) as moderate/severe, with 65% of these patients reporting no medical explanation for their pain. The majority (81%) of the patients were prescribed selective serotonin reuptake inhibitors (SSRI). During the 6-month follow-up, the majority of the patients (73%) remained on the same antidepressant at the same dose during the course of treatment. Between baseline and 6-month endpoint, French patients improved their mean scores (SD) on the SF-36 physical score by+3.5 (9.0) (P<0.001) and mental score by+20.6 (14.2) (P<0.001); on the EQ-5D Health State Index by+0.37 (0.32) (P<0.001) and the EQ-5D VAS by+32.3 (25.0) (P<0.001); on the HADS depression score by-8.1 (6.0) (P<0.001) and HADS anxiety score by-6.9 (5.0) (P<0.001). Patients with moderate/severe pain at baseline improved their overall pain on a mean VAS score by-34.1 (28.7) (P<0.001).

CONCLUSIONS

More than half of the French patients enrolled in the study experienced pain associated with depression. During follow-up, patients improved all of their outcome measurements (physical and mental SF-36 scores, depression and anxiety HADS scores, pain VAS, EQ-5D Health State Index and VAS) and most patients remained on the same antidepressant at the same dose.

Symptoms of depression in a Hispanic primary care population with and without chronic medical illnesses

OBJECTIVE

To describe somatic and psychiatric symptoms reported by Hispanic primary care patients with and without depression and/or chronic medical illnesses.

METHOD

Adult Hispanic patients (n = 104) in a Mobile Health Program in underserved southern Arizona participated in a survey conducted between September 2006 and February 2007 to obtain information about the somatic and psychiatric symptoms that they were experiencing. They were asked to rate the severity of their symptoms listed in the depression screen Personal Health Questionnaire-9 (PHQ-9), the Symptom Checklist-90-Revised (SCL-90-R), and 5 new symptoms described by patients in focus groups conducted in the first phase of the project. Patients were categorized as depressed if their PHQ-9 scores were 10 or above, and they were further categorized as having or not having chronic illnesses based on self-report. Analyses of variance were conducted for each SCL-90-R symptom dimension to compare across the 4 groups (group 1: not depressed and not medically ill; group 2: medically ill but not depressed; group 3: depressed but not medically ill; and group 4: depressed and medically ill).

RESULTS

Patients with chronic medical illnesses comorbid with depression were found to report significantly more somatic symptoms than those with only chronic medical illnesses or depression alone (P ≤ .001). They also reported significantly more psychopathology than patients with depression alone (P ≤ .05 or better).

CONCLUSIONS

Patients with medical illnesses comorbid with depression are more likely to exhibit psychopathology than patients with medical illnesses or depression alone.

Gender differences in prevalence of depression among patients receiving palliative care: the role of dependency

BACKGROUND

in community studies the prevalence of depression is higher in women than men; however, in palliative care settings this relationship is usually less strong, absent or reversed.

AIM

to identify reasons for excess depression among men receiving palliative care.

DESIGN

cross-sectional study.

SETTING/PARTICIPANTS

we interviewed 300 patients recruited from a large hospice in South East London. Depression was measured using the Primary Care Evaluation of Mental Disorder.

RESULTS

the higher prevalence of depression among men was not explained by a higher prevalence of particular types of cancer nor confounding by other covariates. Possible effect modifiers were examined. Depending on others for help with basic tasks (eating, dressing, washing or using the toilet) was a risk factor for depression in men only, with 37.8% of dependent men being depressed compared to 2.4% of similarly affected women (OR = 24.3, 3.1-193.2, p = 0.003). We observed a dose-response effect between the level of dependency and depression in men (p for trend = 0.01).

CONCLUSION

depending on others for help with basic tasks appears to contribute to the burden of depression among men with terminal illness. This gender-specific association may explain why the usual gender differences in depression prevalence are not observed in palliative care.

Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial

CONTEXT

Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life.

OBJECTIVE

To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD.

DESIGN

Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels.

SETTING

Fourteen primary care clinics of an integrated health care system.

PATIENTS

Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD.

INTERVENTION

Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors.

MAIN OUTCOME MEASURES

Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months.

RESULTS

Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, -$3241 to $2053) relative to UC patients.

CONCLUSIONS

For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00468676

Quality of life, diagnosis, and treatment of patients with major depression: a prospective cohort study in primary care

OBJECTIVE

To describe the demographic and clinical characteristics, adequacy of antidepressant treatment, and changes in quality of life of patients with major depression receiving follow-up care from primary care centers.

METHOD

A cohort study was performed in which major depression patients were followed-up over a nine-month period. Several evaluation instruments were used, including the World Health Organization Quality of Life and the Quality of Life-Depression, Centers for Epidemiologic Studies-Depression questionnaires.

RESULTS

The sample comprised 179 individuals, mostly female (73%), with a mean age of 38 years and mean education of 9 years. At the end of the follow-up period, 42% of the individuals still presented with major depression, 25% had complete symptom remission, and only 9% were properly treated with antidepressants. In relation to quality of life, there were significant differences especially between baseline and after nine months in almost all measures.

CONCLUSION

This study demonstrated that depressive symptoms are poorly recognized and that treatment is often inadequate for patients followed-up in primary care units in the south of Brazil. Most of the patients continued to have symptoms of depression over the nine-month period which were associated with impaired quality of life.

Psychosocial and neurocognitive profiles in depressed patients with major depressive disorder and bipolar disorder

Previous studies have revealed psychosocial and cognitive impairments in patients during depression. The primary aim of this study was to investigate whether patients with major depression (MDD) and bipolar disorder (BD) differ in psychosocial and neurocognitive profiles. A second aim was to examine whether cognitive impairments are homogeneous among depressed patients. Patients with MDD (n=16) and BD (n=14) were enrolled during a major depressive episode. About half of them had comorbidities, including personality, substance use, and anxiety disorders. Information was collected about symptomatology and psychosocial functioning, whereas an exhaustive neuropsychological battery was administered to assess cognition. During a depressive episode, MDD and BD patients had global psychosocial dysfunction, characterized by occupational and relational impairments. A cognitive slowing was also observed, as well as deficits related to alertness, spontaneous flexibility, sustained and divided attention. Moreover, severity of depression and cognitive functions were significantly associated with psychosocial functioning. In the case of severe mood disorders, psychosocial and neurocognitive functioning seem similar among MDD and BD patients during a depressive episode. In addition to an altered daily functioning, the neurocognitive profile was heterogeneous with regard to the nature and extent of cognitive deficits. Executive functions, as well as verbal learning and memory, were preserved better than attentional processes.

Loss of interest, depressed mood and impact on the quality of life: cross-sectional survey

BACKGROUND

Depressive symptoms and chronic disease have adverse effects on patients' health-related quality of life (H-RQOL). However, little is known about this effect on H-RQOL when only the two core depressive symptoms - loss of interest and depressed mood - are considered. The objective of this study is to investigate H-RQOL in the presence of loss of interest and depressed mood at a general medical outpatient unit.

METHODS

We evaluated 553 patients at their first attendance at a general medical outpatient unit of a teaching hospital. H-RQOL was assessed with the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). Depressed mood and loss of interest were assessed by the Primary Care Evaluation of Mental Disorders (PRIME-MD)-Patient Questionnaire. A physician performed the diagnosis of chronic diseases by clinical judgment and classified them in 13 possible pre-defined categories. We used multiple linear regression to investigate associations between each domain of H-RQOL and our two core depression symptoms. The presence of chronic diseases and demographic variables were included in the models as covariates.

RESULTS

Among the 553 patients, 70.5% were women with a mean age of 41.0 years (range 18-85, SD ± 15.4). Loss of interest was reported by 54.6%, and depressed mood by 59.7% of the patients. At least one chronic disease was diagnosed in 59.5% of patients; cardiovascular disease was the most prevalent, affecting 20.6% of our patients. Loss of interest and depressed mood was significantly associated with decreased scores in all domains of H-RQOL after adjustment for possible confounders. The presence of any chronic disease was associated with a decrease in the domain of vitality. The analysis of each individual chronic disease category revealed that no category was associated with a decrease in more than one domain of H-RQOL.

CONCLUSION

Loss of interest and depressed mood were associated with significant decreases in H-RQOL. We recommend these simple tests for screening in general practice.

Antidepressant prescribing patterns in Korea: results from the clinical research center for depression study

OBJECTIVE

This study aimed to investigate antidepressant prescribing patterns, including initial choice, switching and combining, and concomitant use of non-antidepressant agents, for depressive disorders in naturalistic clinical care settings in Korea.

METHODS

Patients with depressive disorder were recruited from both outpatient and inpatient settings in 18 hospitals from all over Korea. Treatment was performed in naturalistic patterns based on each clinician's decision. Data were collected on the prescription of antidepressants and concomitant agents from baseline to 12-week follow-up.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed initial antidepressant (48.9%), followed by newer dual-action antidepressants (45.8%). When an SSRI was the initial antidepressant, 46.2% of patients whose medication was changed were moved to newer dual-action antidepressants, and 67.4% of combination cases were combined with newer dual-action ones. When a newer dual-action antidepressant was the initial antidepressant, 70.6% of patients whose medication was changed were moved to SSRIs, and other antidepressants including tricyclic antidepressants were most commonly added for combination treatment (50% of combination cases). During the treatment period, 20.6% of antidepressants prescribed were augmented by non-antidepressant agents, and 75.1% were used concomitantly with anxiolytics or hypnotics. The most commonly used concomitant non-antidepressant agent was quetiapine.

CONCLUSION

The selection of antidepressants and the concomitant use of non-antidepressant agents are becoming increasingly diversified, and the results of this study reflect changes in the prescribing pattern in actual Korean practices.

Anxiety, depression, and quality of life in primary care patients

BACKGROUND

Anxiety and depressive disorders have a significant and negative impact on quality of life. However, less is known about the effects of anxiety and depressive symptoms on quality of life. The purpose of this study was to examine the impact of anxiety and depressive symptoms on emotional and physical functioning, the effects of anxiety symptoms on functioning independent of depressive symptoms, and the effects of depressive symptoms on functioning independent of anxiety symptoms.

METHOD

Participants included 919 patients, recruited from 2 university-affiliated primary care clinics between May 2004 and September 2006, who completed self-report measures of anxiety symptoms, depressive symptoms, and quality of life.

RESULTS

Almost 40% of the sample reported anxiety symptoms and 30% reported depressive symptoms. In both unadjusted and adjusted models, anxiety and depressive symptoms were significantly associated with all domains of quality of life. When anxiety and depressive symptoms were added simultaneously, both remained significant. As the severity of anxiety or depressive symptoms increased, quality of life decreased. Furthermore, patients with moderate to severe anxiety or depressive symptoms had greater impairments in most quality of life domains than patients with acute myocardial infarction, congestive heart failure, or diabetes.

CONCLUSION

Detection and treatment of anxiety and depressive symptoms in the primary care setting should be emphasized.

A computer-assisted depression intervention in primary care

BACKGROUND

The clinical benefit for depression of an interactive computer-assisted cognitive-behavioral program on CD-ROM, the Wellness Workshop (WW), was evaluated in a randomized controlled trial.

METHOD

A total of 191 individuals referred by primary-care physicians were randomly assigned to a control group, where physician-directed treatment as usual (TAU) was provided, or to a treatment group, where TAU was supplemented with the WW CD-ROM, delivered by mail (WW+TAU). Data were collected at baseline, at 6 weeks' post-intervention, and at a 6-month follow-up assessment. Participants were given a strong incentive by a reimbursement of $75 for completion of each assessment. Measures included symptom ratings obtained via structured clinical diagnostic interviews, as well as a battery of self-report questionnaires on symptoms specifically targeted by the intervention.

RESULTS

Analysis of results demonstrated evidence for skill acquisition for improving dysfunctional thinking and reducing anxiety. Among those who met diagnostic criteria for depression, WW+TAU participants were three times more likely to remit at 6 weeks' post-test than TAU participants.

CONCLUSIONS

The evidence supports the conclusion that the WW intervention added benefit to traditional care for depression. No placebo comparison group was included and the WW+TAU participants received slightly more attention (a supportive telephone contact, ≤ 5 min from a psychologist 2 weeks after receiving the program). Overall, the findings add support to the accumulating evidence for the potential clinical benefit of computer-assisted behavioral health interventions.

Health-related quality of life is worse in individuals with hypertension under drug treatment: results of population-based study

Patients with hypertension usually report lower health-related quality of life (HRQoL), but it is unclear whether this is secondary to high blood pressure (BP) per se, drug treatment or awareness of disease. In a cross-sectional study using a multistage population-based sample, participants were interviewed and examined at home. Hypertension was defined by BP ≥140/90 mm Hg or use of BP-lowering drugs. HRQoL was assessed through the Short-Form Health Survey (SF-12) and presented as the physical component summary (PCS), mental component summary (MCS) and the SF-12 eight-domain scale. In total, 1858 individuals were evaluated, being 60.1% women, aged 52.5 ± 4.1 years old, and 39.9% men, aged 47.2 ± 9.1 years old. Prevalence of hypertension was 34.2% (95% CI 31.5-36.9). The PCS scores for hypertensive and normotensive participants were 49.4 (CI 48.6-50.2) and 51.06 (CI 50.4-51.7) (P=0.01), respectively, and the MCS scores were 49.1 (CI 47.9-50.3) and 50.5 (CI 49.6-51.2) (P=0.06), respectively. Participants with hypertension and not using BP drugs had higher HRQoL scores (PCS 49.6; MCS 51.9) than those using BP drugs either with uncontrolled (PCS 45.3; MCS 49.4) or controlled BP (PCS 46.2; MCS 47.7; P<0.05). We concluded that individuals with hypertension have worse quality of life, particularly when their BP is controlled by drugs. This perception may lead to lower rates of adherence to treatment.