Standardized clinical outcome rating scale for depression for use in clinical practice

An integrative review of the evidence for Shinrin-Yoku (Forest Bathing) in the management of depression and its potential clinical application in evidence-based osteopathy

There is growing interest in the idea of integrating Nature Therapies into the multidisciplinary management of complex conditions such as depression. Shinrin-Yoku (Forest Bathing), a practice involving spending time in a forested environment while paying attention to multi-sensory stimuli has been proposed as one such modality. The objectives of this review were to critically analyse the current evidence base on the efficacy of Shinrin-Yoku for the treatment of depression, and to examine how the findings may reflect and/or inform osteopathic principles and clinical practice. An integrative review of the evidence for Shinrin-Yoku in the management of depression published between 2009 and 2019 was conducted resulting in n = 13 peer-reviewed studies meeting inclusion criteria. Two themes emerged from the literature, the positive effect of Shinrin-Yoku on self-reported mood scores, and physiological changes arising from forest exposure. However, the methodological quality of the evidence is poor and experiments may not be generalisable. Suggestions were made for improving the research base via mixed-method studies in a biopsychosocial framework, and aspects of the research which may be applicable to evidence-based osteopathy were noted.

The use of brexpiprazole amongst individuals with insufficient outcomes with aripiprazole or bupropion: A case series

PURPOSE

We sought to characterize the clinical experience of outpatients treated with brexpiprazole after achieving suboptimal outcomes with aripiprazole or bupropion as determined by the treating psychiatric provider.

DESIGN AND METHODS

Case series; inefficacy, intolerability, or other unsatisfactory outcome to previous trial with aripiprazole or bupropion.

FINDINGS

The majority of individuals in our sample exhibited tolerability of brexpiprazole. In addition, reduction in mean PHQ-9 scores was observed with brexpiprazole treatment.

IMPLICATIONS

The results of our preliminary analysis suggest that a subpopulation of adults who have insufficient outcomes on aripiprazole or bupropion due to intolerability, inefficacy or other unsatisfactory outcome may benefit by switching to brexpiprazole treatment. Larger randomized controlled trials are needed, as well as sophisticated network analysis to further understand efficacy and tolerability differences between atypical antipsychotics.

Adolescent eating disorders: treatment and response in a naturalistic study

This naturalistic study investigated the treatment and outcome of adolescents with eating disorders (EDs) in the community. Clinicians from a practice-research network provided data on ED symptoms, global functioning, comorbidity, treatment, and outcome for 120 adolescents with EDs. ED "not otherwise specified" was the most common ED diagnosed. After an average of 8 months of treatment, about one third of patients had recovered, with patients with anorexia nervosa showing the most improvement. Clinicians utilized a range of psychotherapy interventions and two thirds of the patients had received adjunct psychoactive medication. Although CBT showed the strongest association with outcome in a subsample characterized by poor relational/personality functioning, dynamic therapy was associated with better global outcome in the overall sample.

Relationship of residual mood and panic-agoraphobic spectrum phenomenology to quality of life and functional impairment in patients with major depression

The aim of this study was to analyze the relationship of residual mood and panic-agoraphobic spectrum phenomenology to functional impairment and quality of life in 226 adult outpatients who had remitted from a major depressive episode. Quality of life and functioning were assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire and the Work and Social Adjustment Scale. Residual symptoms were assessed using the Mood and Panic-Agoraphobic Spectrum Questionnaires. Linear and logistic regression models were used to analyze the relationship of mood and panic-agoraphobic spectrum factors with quality of life and functioning. Poor quality of life was associated with the Mood Spectrum Self-Report Questionnaire factors 'depressive mood' and 'psychotic features' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factors 'separation anxiety' and 'loss sensitivity'. Functional impairment was associated with the Mood Spectrum Self-Report Questionnaire factor 'psychomotor retardation' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factor 'fear of losing control'. These relationships were held after controlling for the severity of depression at the entry in the continuation treatment phase. In conclusion, the spectrum assessment is a useful tool for clinicians to identify areas of residual symptomatology that can be targeted with focused and effective long-term treatment strategies.

A clinically useful depression outcome scale

If the optimal delivery of mental health treatment ultimately depends on examining outcome, then precise, reliable, valid, informative, and user-friendly measurement is the key to evaluating the quality and efficiency of care in clinical practice. Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the reliability and validity of the Clinically Useful Depression Outcome Scale (CUDOS). The CUDOS was designed to be brief (completed in less than 3 minutes), quickly scored (in less than 15 seconds), clinically useful (fully covering the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of major depressive disorder and dysthymic disorder), reliable, valid, and sensitive to change. We studied the CUDOS in more than 1400 psychiatric outpatients and found that the scale had high internal consistency and test-retest reliability. The CUDOS was more highly correlated with another self-report measure of depression than with measures of anxiety, substance use problems, eating disorders, and somatization, thereby supporting the convergent and discriminant validity of the scale. The CUDOS was also highly correlated with interviewer ratings of the severity of depression, and CUDOS scores were significantly different in depressed patients with mild, moderate, and severe levels of depression. The CUDOS was a valid measure of symptom change. Finally, the CUDOS was significantly associated with a diagnosis of major depressive disorder. Thus, the results of this large validation study of the CUDOS shows that it is a reliable and valid measure of depression that is feasible to incorporate into routine clinical practice.

Heterogeneity among depressed outpatients considered to be in remission

More than a decade ago, a consensus panel recommended that remission be defined on the 17-item version of the Hamilton Rating Scale for Depression (HAM-D) as a cutoff of less than 7. Recently, some investigators have suggested that this threshold to define remission may be too high. If true, this means that heterogeneity exists within the group of treatment remitters accounting for variance in psychosocial function and relapse risk. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether there is heterogeneity within the group of patients that are typically classified as remitters. Three hundred three depressed psychiatric outpatients were rated on the Standardized Clinical Outcome Rating for Depression, an index of Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition remission status, and the 17-item HAM-D. Approximately half of the patients completed a measure of psychosocial impairment. Treatment responders were divided into 2 groups, remitters (HAM-D < or =7) and nonremitters (HAM-D > or =8). The treatment remitters were further subdivided into 2 groups, remitters with and without mild residual symptoms (HAM-D 3-7 vs 0-2). We refer to these 3 nonoverlapping groups as responders, partial remitters (ie, remitters with mild residual symptoms), and full remitters (remitters without residual symptoms). Responders scored statistically significantly higher, indicating greater psychosocial impairment, than the entire group of remitters, and the partial remitters scored significantly higher than the full remitters. Among the responders, the correlation between remission status and functioning was -.49 (P < .01). Among the remitters, the correlation between residual symptom status and functioning was nearly as high (-.42, P < .05). These results suggest that there is as much heterogeneity among patients who are typically considered to be in remission as there is among responders. This supports recommendations to lower the cutoff on the HAM-D to define remission.

The impact of gender, age and depressed state on patients' perspectives of remission

BACKGROUND

Current standards for treatment outcome from major depression assess remission solely from the vantage point of symptom resolution. Recent evidence, however, suggests that depressed patients consider factors beyond symptom resolution as important for defining remission. The goal of this study was to examine the influence of three predictors on patients' views of factors important for achieving remission: gender, age and current depressed state (i.e., remitted or depressed).

METHODS

Five hundred and sixty-two depressed psychiatric outpatients completed a survey assessing the importance of 16 remission factors. Depressed state was assessed by the Standardized Clinical Outcome Rating scale for Depression (SCOR-D), a clinician rated scale that is based on the number of DSM-IV criteria for a major depressive episode and level of psychosocial impairment present during the past week.

RESULTS

Relative to male patients, females showed a greater likelihood for rating remission factors related to emotional stabilization (e.g., achieving emotional control, being able to cope with normal stress) as very important. Relative to younger cohorts, the oldest depressed patients endorsed a greater number of remission factors as very important and emphasized positive mental health states (e.g., feeling satisfied, having a general sense of well-being) more. There were no significant differences between remitted and depressed patients in rating the remission factors' importance.

CONCLUSION

Perspectives on remission may be differentially perceived by women versus men and by older versus younger depressed patients.

LIMITATIONS

The study was conducted in a single outpatient clinical practice.