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Chen Z, Ou Y, Liu F, Li H, Li P, Xie G, Cui X, Guo W. Increased brain nucleus accumbens functional connectivity in melancholic depression. Neuropharmacology 2024; 243:109798. [PMID: 37995807 DOI: 10.1016/j.neuropharm.2023.109798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Melancholic depression, marked by typical symptoms of anhedonia, is regarded as a homogeneous subtype of major depressive disorder (MDD). However, little attention was paid to underlying mechanisms of melancholic depression. This study aims to examine functional connectivity of the reward circuit associated with anhedonia symptoms in melancholic depression. METHODS Fifty-nine patients with first-episode drug- naive MDD, including 31 melancholic patients and 28 non-melancholic patients, were recruited and underwent resting-state functional magnetic resonance imaging (rs-fMRI). Thirty-two healthy volunteers were recruited as controls. Bilateral nucleus accumbens (NAc) were selected as seed points to form functional NAc network. Then support vector machine (SVM) was used to distinguish melancholic patients from non-melancholic patients. RESULTS Relative to non-melancholic patients, melancholic patients displayed increased functional connectivity (FC) between bilateral NAc and right middle frontal gyrus (MFG) and between right NAc and left cerebellum lobule VIII. Compared to healthy controls, melancholic patients showed increased FC between right NAc and right lingual gyrus and between left NAc and left postcentral gyrus; non-melancholic patients had increased FC between bilateral NAc and right lingual gyrus. No significant correlations were observed between altered FC and clinical variables in melancholic patients. SVM results showed that FC between left NAc and right MFG could accurately distinguish melancholic patients from non-melancholic patients. CONCLUSION Melancholic depression exhibited different patterns of functional connectivity of the reward circuit relative to non-melancholic patients. This study highlights the significance of the reward circuit in the neuropathology of melancholic depression.
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Affiliation(s)
- Zhaobin Chen
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Yangpan Ou
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Feng Liu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin 300000, China
| | - Huabing Li
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Ping Li
- Department of Psychiatry, Qiqihar Medical University, Qiqihar, Heilongjiang 161006, China
| | - Guangrong Xie
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Xilong Cui
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China.
| | - Wenbin Guo
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China.
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Buss JF, Watts AL, Lorenzo-Luaces L. Methods for quantifying the heterogeneity of psychopathology. BMC Psychiatry 2023; 23:897. [PMID: 38037069 PMCID: PMC10690966 DOI: 10.1186/s12888-023-05377-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES Specifiers for a major depressive disorder (MDE) are supposed to reduce diagnostic heterogeneity. However, recent literature challenges the idea that the atypical and melancholic specifiers identify more homogenous or coherent subgroups. We introduce the usage of distance metrics to characterize symptom heterogeneity. We attempt to replicate prior findings and explore whether symptom heterogeneity is reduced using specifier subgroups. METHODS We used data derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC Wave I; N = 5,749) and the Sequenced Treatment Alternatives to Relieve Depression study (STAR*D; N = 2,498). We computed Hamming and Manhattan distances from study participants' unique symptom profiles. Distances were standardized from 0-1 and compared by their within- and between-group similarities to their non-specifier counterparts for the melancholic and atypical specifiers. RESULTS There was no evidence of statistically significant differences in heterogeneity for specifier (i.e., melancholic or atypical) vs. non-specifier designations (i.e., non-melancholic vs. non-atypical). CONCLUSION Replicating prior work, melancholic and atypical depression specifiers appear to have limited utility in reducing heterogeneity. The current study does not support the claim that specifiers create more coherent subgroups as operationalized by similarity in the number of symptoms and their severity. Distance metrics are useful for quantifying symptom heterogeneity.
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Affiliation(s)
- John F Buss
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN 47405, USA.
| | - Ashley L Watts
- Department of Psychology, Vanderbilt University, Nashville, TN 37420, USA
| | - Lorenzo Lorenzo-Luaces
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN 47405, USA
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Cuijpers P, Miguel C, Harrer M, Plessen CY, Ciharova M, Papola D, Ebert D, Karyotaki E. Psychological treatment of depression: A systematic overview of a 'Meta-Analytic Research Domain'. J Affect Disord 2023; 335:141-151. [PMID: 37178828 DOI: 10.1016/j.jad.2023.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Over the past 16 years, we have developed a 'Meta-analytic Research Domain' (MARD) of all randomized trials of psychological treatments of depression. A MARD is a living systematic review of a research field, that cannot be otherwise covered by one (network) meta-analysis and includes multiple PICOs. In this paper we give an overview of the findings of this MARD. METHODS A narrative review of the results of the 118 meta-analyses on psychotherapies for depression that were published within our MARD. RESULTS Most research has been conducted on cognitive-behavioral therapy (CBT), but several other psychotherapies are also effective, with few differences between therapies. They can be effectively delivered in individual, group, telephone and guided self-help format and are effective in many different target groups and across different age groups, although the effects are significantly smaller in children and adolescents. Psychotherapies have comparable effects as pharmacotherapy at the short term but are probably more effective at the longer term. Combined treatment is more effective than either psychotherapy or pharmacotherapy alone at the short, but also at the longer term. LIMITATIONS We did not summarize all published meta-analyses (protocols, methodological studies) and have not compared our results to those found in other meta-analyses on comparable subjects. CONCLUSION Psychotherapies can contribute considerably to a reduction of the disease burden of depression. MARDs are an important next step in the aggregation of knowledge from randomized controlled trials in psychological treatments of depression as well as in other healthcare sectors.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, the Netherlands; Babeș-Bolyai University, International Institute for Psychotherapy, Cluj-Napoca, Romania.
| | - Clara Miguel
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Mathias Harrer
- Psychology & Digital Mental Health Care, Department of Health Sciences, Technical University Munich, Munich, Germany; Department of Clinical Psychology & Psychotherapy, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Constantin Yves Plessen
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, the Netherlands; Department of Psychosomatic Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marketa Ciharova
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Davide Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Science, Section of Psychiatry, University of Verona, Italy; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - David Ebert
- Psychology & Digital Mental Health Care, Department of Health Sciences, Technical University Munich, Munich, Germany
| | - Eirini Karyotaki
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, the Netherlands
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Tanguay-Sela M, Rollins C, Perez T, Qiang V, Golden G, Tunteng JF, Perlman K, Simard J, Benrimoh D, Margolese HC. A systematic meta-review of patient-level predictors of psychological therapy outcome in major depressive disorder. J Affect Disord 2022; 317:307-318. [PMID: 36029877 DOI: 10.1016/j.jad.2022.08.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Psychological therapies are effective for treating major depressive disorder, but current clinical guidelines do not provide guidance on the personalization of treatment choice. Established predictors of psychotherapy treatment response could help inform machine learning models aimed at predicting individual patient responses to different therapy options. Here we sought to comprehensively identify known predictors. METHODS EMBASE, Medline, PubMed, PsycINFO were searched for systematic reviews with or without meta-analysis published until June 2020 to identify individual patient-level predictors of response to psychological treatments. 3113 abstracts were identified and 300 articles assessed. We qualitatively synthesized our findings by predictor category (sociodemographic; symptom profile; social support; personality features; affective, cognitive, and behavioural; comorbidities; neuroimaging; genetics) and treatment type. We used the AMSTAR 2 to evaluate the quality of included reviews. RESULTS Following screening and full-text assessment, 27 systematic reviews including 12 meta-analyses were eligible for inclusion. 74 predictors emerged for various psychological treatments, primarily cognitive behavioural therapy, interpersonal therapy, and mindfulness-based cognitive therapy. LIMITATIONS A paucity of studies examining predictors of psychological treatment outcome, as well as methodological heterogeneities and publication biases limit the strength of the identified predictors. CONCLUSIONS The synthesized predictors could be used to supplement clinical decision-making in selecting psychological therapies based on individual patient characteristics. These predictors could also be used as a priori input features for machine learning models aimed at predicting a given patient's likelihood of response to different treatment options for depression, and may contribute toward the development of patient-specific treatment recommendations in clinical guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - Jade Simard
- Université du Québec à Montréal, Montreal, Quebec, Canada
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Fu X, Yang X, Cui X, Liu F, Li H, Yan M, Xie G, Guo W. Overlapping and segregated changes of functional hubs in melancholic depression and non-melancholic depression. J Psychiatr Res 2022; 154:123-131. [PMID: 35933856 DOI: 10.1016/j.jpsychires.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous research found associations between neuropsychiatric disorders and patterns of highly connected "hub" nodes, which are crucial in coordinating brain functions. Melancholic depression is considered a relatively distinct and homogenous subtype of major depressive disorder (MDD), which responds better to pharmacological treatments than placebos or psychotherapies. Accordingly, melancholic depression probably has distinct neuropathological underpinnings. This study aims to examine the overlapping and segregated changes of functional hubs in melancholic and non-melancholic MDD. METHODS Thirty-one melancholic patients, 28 non-melancholic patients, and 32 healthy controls were included. Resting-state functional imaging data were analyzed using global functional connectivity. RESULTS Both melancholic and non-melancholic patients had increased GFC in the bilateral insula and decreased GFC in the PCC/precuneus compared to HCs. The distinction was that melancholic patients showed increased GFC in the bilateral thalamus, right inferior parietal lobule (IPL), and left cerebellum Crus I and decreased GFC in the left temporal lobe, whereas non-melancholic patients showed increased GFC in the left superior parietal lobe. Additionally, compared with non-melancholic patients, melancholic individuals displayed significant increases of GFC in the left IPL and cerebellum. CONCLUSION Increased GFC of the insula and decreased GFC of the PCC and precuneus are the common abnormalities of melancholic and non-melancholic MDD. Hyperconnectivity of the IPL and cerebellum might be distinctive neuropathological features of melancholic MDD.
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Affiliation(s)
- Xiaoya Fu
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Xiaolun Yang
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Xilong Cui
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Feng Liu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, 300000, China
| | - Huabing Li
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Meiqi Yan
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Guangrong Xie
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| | - Wenbin Guo
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China; Department of Psychiatry, The Third People's Hospital of Foshan, Foshan, Guangdong, 528000, China; Department of Psychiatry, Qiqihar Medical University, Qiqihar, Heilongjiang, 161006, China.
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Lorenzo-Luaces L, Buss JF, Fried EI. Heterogeneity in major depression and its melancholic and atypical specifiers: a secondary analysis of STAR*D. BMC Psychiatry 2021; 21:454. [PMID: 34530785 PMCID: PMC8447832 DOI: 10.1186/s12888-021-03444-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The melancholic and atypical specifiers for a major depressive episode (MDE) are supposed to reduce heterogeneity in symptom presentation by requiring additional, specific features. Fried et al. (2020) recently showed that the melancholic specifier may increase the potential heterogeneity in presenting symptoms. In a large sample of outpatients with depression, our objective was to explore whether the melancholic and atypical specifiers reduced observed heterogeneity in symptoms. METHODS We used baseline data from the Inventory of Depression Symptoms (IDS), which was available for 3,717 patients, from the Sequenced Alternatives to Relieve Depression (STAR*D) trial. A subsample met criteria for MDE on the IDS ("IDS-MDE"; N =2,496). For patients with IDS-MDE, we differentiated between those with melancholic, non-melancholic, non-melancholic, atypical, and non-atypical depression. We quantified the observed heterogeneity between groups by counting the number of unique symptom combinations pertaining to their given diagnostic group (e.g., counting the melancholic symptoms for melancholic and non-melancholic groups), as well as the profiles of DSM-MDE symptoms (i.e., ignoring the specifier symptoms). RESULTS When considering the specifier and depressive symptoms, there was more observed heterogeneity within the melancholic and atypical subgroups than in the IDS-MDE sample (i.e., ignoring the specifier subgroups). The differences in number of profiles between the melancholic and non-melancholic groups were not statistically significant, irrespective of whether focusing on the specifier symptoms or only the DSM-MDE symptoms. The differences between the atypical and non-atypical subgroups were smaller than what would be expected by chance. We found no evidence that the specifier groups reduce heterogeneity, as can be quantified by unique symptom profiles. Most symptom profiles, even in the specifier subgroups, had five or fewer individuals. CONCLUSION We found no evidence that the atypical and melancholic specifiers create more symptomatically homogeneous groups. Indeed, the melancholic and atypical specifiers introduce heterogeneity by adding symptoms to the DSM diagnosis of MDE.
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Affiliation(s)
- Lorenzo Lorenzo-Luaces
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, 47405 IN USA
| | - John F. Buss
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, 47405 IN USA
| | - Eiko I. Fried
- Department of Psychology, Leiden University, Leiden, 2333 AK Netherlands
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Bartova L, Fugger G, Dold M, Swoboda MMM, Zohar J, Mendlewicz J, Souery D, Montgomery S, Fabbri C, Serretti A, Kasper S. Combining psychopharmacotherapy and psychotherapy is not associated with better treatment outcome in major depressive disorder - evidence from the European Group for the Study of Resistant Depression. J Psychiatr Res 2021; 141:167-175. [PMID: 34216945 DOI: 10.1016/j.jpsychires.2021.06.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/08/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
Despite plenty of effective antidepressant (AD) treatments, the outcome of major depressive disorder (MDD) is often unsatisfactory, probably due to improvable exploitation of available therapies. This European, cross-sectional, naturalistic multicenter study investigated the frequency of additional psychotherapy in terms of a manual-driven psychotherapy (MDP) in 1410 adult in- and outpatients with MDD, who were primarily treated with AD psychopharmacotherapy. Socio-demographic and clinical patterns were compared between patients receiving both treatments and those lacking concomitant MDP. In a total of 1279 MDD patients (90.7%) with known status of additional MDP, those undergoing a psychopharmacotherapy-MDP combination (31.2%) were younger, higher educated, more often employed and less severely ill with lower odds for suicidality as compared to patients receiving exclusively psychopharmacotherapy (68.8%). They experienced an earlier mean age of MDD onset, melancholic features, comorbid asthma and migraine and received lower daily doses of their first-line ADs. While agomelatine was more often established in these patients, MDD patients without MDP received selective serotonin reuptake inhibitors more frequently. These two patient groups did not differ in terms of response, non-response and treatment resistant depression (TRD). Accordingly, the employment of additional MDP could not be related to better treatment outcomes in MDD. The fact that MDP was applied in a minority of patients with rather beneficial socio-demographic and clinical characteristics might reflect inferior accessibility of these psychotherapeutic techniques for socially and economically disadvantaged populations.
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Affiliation(s)
- Lucie Bartova
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Gernot Fugger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Markus Dold
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | | | - Joseph Zohar
- Psychiatric Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | - Daniel Souery
- School of Medicine, Free University of Brussels, Brussels, Belgium; Psy Pluriel - European Centre of Psychological Medicine, Brussels, Belgium
| | - Stuart Montgomery
- Imperial College School of Medicine, University of London, London, United Kingdom
| | - Chiara Fabbri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Center for Brain Research, Medical University of Vienna, Vienna, Austria.
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Dold M, Bartova L, Fugger G, Kautzky A, Mitschek MMM, Fabbri C, Montgomery S, Zohar J, Souery D, Mendlewicz J, Serretti A, Kasper S. Melancholic features in major depression - a European multicenter study. Prog Neuropsychopharmacol Biol Psychiatry 2021; 110:110285. [PMID: 33609603 DOI: 10.1016/j.pnpbp.2021.110285] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/31/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
There is still a debate, if melancholic symptoms can be seen rather as a more severe subtype of major depressive disorder (MDD) or as a separate diagnostic entity. The present European multicenter study comprising altogether 1410 MDD in- and outpatients sought to investigate the influence of the presence of melancholic features in MDD patients. Analyses of covariance, chi-squared tests, and binary logistic regression analyses were accomplished to determine differences in socio-demographic and clinical variables between MDD patients with and without melancholia. We found a prevalence rate of 60.71% for melancholic features in MDD. Compared to non-melancholic MDD patients, they were characterized by a significantly higher likelihood for higher weight, unemployment, psychotic features, suicide risk, inpatient treatment, severe depressive symptoms, receiving add-on medication strategies in general, and adjunctive treatment with antidepressants, antipsychotics, benzodiazepine (BZD)/BZD-like drugs, low-potency antipsychotics, and pregabalin in particular. With regard to the antidepressant pharmacotherapy, we found a less frequent prescription of selective serotonin reuptake inhibitors (SSRIs) in melancholic MDD. No significant between-group differences were found for treatment response, non-response, and resistance. In summary, we explored primarily variables to be associated with melancholia which can be regarded as parameters for the presence of severe/difficult-to treat MDD conditions. Even if there is no evidence to realize any specific treatment strategy in melancholic MDD patients, their prescribed medication strategies were different from those for patients without melancholia.
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Affiliation(s)
- Markus Dold
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Lucie Bartova
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Gernot Fugger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Alexander Kautzky
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Marleen M M Mitschek
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Chiara Fabbri
- Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | | | - Joseph Zohar
- Psychiatric Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Daniel Souery
- School of Medicine, Free University of Brussels, Brussels, Belgium; Psy Pluriel - European Centre of Psychological Medicine, Brussels, Belgium
| | | | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria; Center for Brain Research, Medical University of Vienna, Vienna, Austria.
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Circadian depression: A mood disorder phenotype. Neurosci Biobehav Rev 2021; 126:79-101. [PMID: 33689801 DOI: 10.1016/j.neubiorev.2021.02.045] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/18/2021] [Accepted: 02/28/2021] [Indexed: 12/15/2022]
Abstract
Major mood syndromes are among the most common and disabling mental disorders. However, a lack of clear delineation of their underlying pathophysiological mechanisms is a major barrier to prevention and optimised treatments. Dysfunction of the 24-h circadian system is a candidate mechanism that has genetic, behavioural, and neurobiological links to mood syndromes. Here, we outline evidence for a new clinical phenotype, which we have called 'circadian depression'. We propose that key clinical characteristics of circadian depression include disrupted 24-h sleep-wake cycles, reduced motor activity, low subjective energy, and weight gain. The illness course includes early age-of-onset, phenomena suggestive of bipolarity (defined by bidirectional associations between objective motor and subjective energy/mood states), poor response to conventional antidepressant medications, and concurrent cardiometabolic and inflammatory disturbances. Identifying this phenotype could be clinically valuable, as circadian-targeted strategies show promise for reducing depressive symptoms and stabilising illness course. Further investigation of underlying circadian disturbances in mood syndromes is needed to evaluate the clinical utility of this phenotype and guide the optimal use of circadian-targeted interventions.
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Personalized Medicine and Cognitive Behavioral Therapies for Depression: Small Effects, Big Problems, and Bigger Data. Int J Cogn Ther 2020. [DOI: 10.1007/s41811-020-00094-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Maj M, Stein DJ, Parker G, Zimmerman M, Fava GA, De Hert M, Demyttenaere K, McIntyre RS, Widiger T, Wittchen HU. The clinical characterization of the adult patient with depression aimed at personalization of management. World Psychiatry 2020; 19:269-293. [PMID: 32931110 PMCID: PMC7491646 DOI: 10.1002/wps.20771] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Depression is widely acknowledged to be a heterogeneous entity, and the need to further characterize the individual patient who has received this diagnosis in order to personalize the management plan has been repeatedly emphasized. However, the research evidence that should guide this personalization is at present fragmentary, and the selection of treatment is usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the particular features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission with the first treatment they receive. The predominant pessimism about the actual feasibility of the personalization of treatment of depression in routine clinical practice has recently been tempered by some secondary analyses of databases from clinical trials, using approaches such as individual patient data meta-analysis and machine learning, which indicate that some variables may indeed contribute to the identification of patients who are likely to respond differently to various antidepressant drugs or to antidepressant medication vs. specific psychotherapies. The need to develop decision support tools guiding the personalization of treatment of depression has been recently reaffirmed, and the point made that these tools should be developed through large observational studies using a comprehensive battery of self-report and clinical measures. The present paper aims to describe systematically the salient domains that should be considered in this effort to personalize depression treatment. For each domain, the available research evidence is summarized, and the relevant assessment instruments are reviewed, with special attention to their suitability for use in routine clinical practice, also in view of their possible inclusion in the above-mentioned comprehensive battery of measures. The main unmet needs that research should address in this area are emphasized. Where the available evidence allows providing the clinician with specific advice that can already be used today to make the management of depression more personalized, this advice is highlighted. Indeed, some sections of the paper, such as those on neurocognition and on physical comorbidities, indicate that the modern management of depression is becoming increasingly complex, with several components other than simply the choice of an antidepressant and/or a psychotherapy, some of which can already be reliably personalized.
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Affiliation(s)
- Mario Maj
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Dan J Stein
- South African Medical Research Council Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Gordon Parker
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Mark Zimmerman
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Marc De Hert
- University Psychiatric Centre KU Leuven, Kortenberg, Belgium
- KU Leuven Department of Neurosciences, Leuven, Belgium
| | - Koen Demyttenaere
- University Psychiatric Centre, University of Leuven, Leuven, Belgium
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Thomas Widiger
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
- Department of Psychiatry and Psychotherapy, Ludwig Maximilans Universität Munich, Munich, Germany
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Milaneschi Y, Lamers F, Berk M, Penninx BWJH. Depression Heterogeneity and Its Biological Underpinnings: Toward Immunometabolic Depression. Biol Psychiatry 2020; 88:369-380. [PMID: 32247527 DOI: 10.1016/j.biopsych.2020.01.014] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/03/2019] [Accepted: 01/18/2020] [Indexed: 12/14/2022]
Abstract
Epidemiological evidence indicates the presence of dysregulated homeostatic biological pathways in depressed patients, such as increased inflammation and disrupted energy-regulating neuroendocrine signaling (e.g., leptin, insulin). Alterations in these biological pathways may explain the considerable comorbidity between depression and cardiometabolic conditions (e.g., obesity, metabolic syndrome, diabetes) and represent a promising target for intervention. This review describes how immunometabolic dysregulations vary as a function of depression heterogeneity by illustrating that such biological dysregulations map more consistently to atypical behavioral symptoms reflecting altered energy intake/expenditure balance (hyperphagia, weight gain, hypersomnia, fatigue, and leaden paralysis) and may moderate the antidepressant effects of standard or novel (e.g., anti-inflammatory) therapeutic approaches. These lines of evidence are integrated in a conceptual model of immunometabolic depression emerging from the clustering of immunometabolic biological dysregulations and specific behavioral symptoms. The review finally elicits questions to be answered by future research and describes how the immunometabolic depression dimension could be used to dissect the heterogeneity of depression and potentially to match subgroups of patients to specific treatments with higher likelihood of clinical success.
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Affiliation(s)
- Yuri Milaneschi
- Department of Psychiatry, Amsterdam Public Health and Amsterdam Neuroscience, Amsterdam University Medical Center/Vrije Universiteit & GGZinGeest, Amsterdam, The Netherlands.
| | - Femke Lamers
- Department of Psychiatry, Amsterdam Public Health and Amsterdam Neuroscience, Amsterdam University Medical Center/Vrije Universiteit & GGZinGeest, Amsterdam, The Netherlands
| | - Michael Berk
- Institute for Mental and Physical Health and Clinical Treatment, School of Medicine, Deakin University and Barwon Health, Geelong, Victoria, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Brenda W J H Penninx
- Department of Psychiatry, Amsterdam Public Health and Amsterdam Neuroscience, Amsterdam University Medical Center/Vrije Universiteit & GGZinGeest, Amsterdam, The Netherlands
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Predicting treatment effects in unipolar depression: A meta-review. Pharmacol Ther 2020; 212:107557. [PMID: 32437828 DOI: 10.1016/j.pharmthera.2020.107557] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/23/2020] [Indexed: 12/23/2022]
Abstract
There is increasing interest in clinical prediction models in psychiatry, which focus on developing multivariate algorithms to guide personalized diagnostic or management decisions. The main target of these models is the prediction of treatment response to different antidepressant therapies. This is because the ability to predict response based on patients' personal data may allow clinicians to make improved treatment decisions, and to provide more efficacious or more tolerable medications to the right patient. We searched the literature for systematic reviews about treatment prediction in the context of existing treatment modalities for adult unipolar depression, until July 2019. Treatment effect is defined broadly to include efficacy, safety, tolerability and acceptability outcomes. We first focused on the identification of individual predictor variables that might predict treatment response, and second, we considered multivariate clinical prediction models. Our meta-review included a total of 10 systematic reviews; seven (from 2014 to 2018) focusing on individual predictor variables and three focusing on clinical prediction models. These identified a number of sociodemographic, phenomenological, clinical, neuroimaging, remote monitoring, genetic and serum marker variables as possible predictor variables for treatment response, alongside statistical and machine-learning approaches to clinical prediction model development. Effect sizes for individual predictor variables were generally small and clinical prediction models had generally not been validated in external populations. There is a need for rigorous model validation in large external data-sets to prove the clinical utility of models. We also discuss potential future avenues in the field of personalized psychiatry, particularly the combination of multiple sources of data and the emerging field of artificial intelligence and digital mental health to identify new individual predictor variables.
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Plöderl M, Hengartner MP. Guidelines for the pharmacological acute treatment of major depression: conflicts with current evidence as demonstrated with the German S3-guidelines. BMC Psychiatry 2019; 19:265. [PMID: 31477074 PMCID: PMC6720867 DOI: 10.1186/s12888-019-2230-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 08/06/2019] [Indexed: 01/03/2023] Open
Abstract
Several international guidelines for the acute treatment of moderate to severe unipolar depression recommend a first-line treatment with antidepressants (AD). This is based on the assumption that AD obviously outperform placebo, at least in the case of severe depression. The efficacy of AD for severe depression can only be definitely clarified with individual patient data, but corresponding studies have only been available recently. In this paper, we point out discrepancies between the content of guidelines and the scientific evidence by taking a closer look at the German S3-guidelines for the treatment of depression. Based on recent studies and a systematic review of studies using individual patient data, it turns out that AD are marginally superior to placebo in both moderate and severe depression. The clinical significance of this small drug-placebo-difference is questionable, even in the most severe forms of depression. In addition, the modest efficacy is likely an overestimation of the true efficacy due to systematic method biases. There is no related discussion in the S3-guidelines, despite substantial empirical evidence confirming these biases. In light of recent data and with their underlying biases, the recommendations in the S3-guidelines are in contradiction with the current evidence. The risk-benefit ratio of AD for severe depression may be similar to the one estimated for mild depression and thus could be unfavorable. Downgrading of the related grade of recommendation would be a logical consequence.
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Affiliation(s)
- Martin Plöderl
- Department for Crisis Intervention and Suicide Prevention, Christian Doppler Clinic, Paracelsus Medicial University, Ignaz Harrer Str. 79, 5020, Salzburg, Austria.
| | - Michael P. Hengartner
- 0000000122291644grid.19739.35Zurich University of Applied Sciences, School of Applied Psychology, Zurich, Switzerland
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A Propensity Score Analysis of Homework Adherence-Outcome Relations in Cognitive Behavioral Therapy for Depression. Behav Ther 2019; 50:285-299. [PMID: 30824246 PMCID: PMC6489494 DOI: 10.1016/j.beth.2018.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 05/15/2018] [Accepted: 05/30/2018] [Indexed: 12/25/2022]
Abstract
Little is known about whether or not a consistently high level of homework adherence over the course of therapy benefits patients. This question was examined in two samples of patients who were receiving individual Cognitive Behavioral Therapy (CBT) for depression (Ns = 128 [Sequenced Treatment Alternatives to Relieve Depression: STAR-D] and 183 [Continuation Phase Cognitive Therapy Relapse Prevention: C-CT-RP]). Logistic and linear regression and propensity score models were used to identify whether or not clinician assessments of homework adherence differentiated symptom reduction and remission, as assessed by the Hamilton Depression Rating Scale-17 (HDRS-17), the Quick Inventory of Depressive Symptomatology-Self-Reported Scale (QIDS-SR), and the QIDS-Clinician Scale (QIDS-C). CBT-related response and remission were equally likely between both high and low homework adherers in both studies and in all models. But in propensity adjusted models that adjusted for session attendance, for both the STAR-D and C-CT-RP samples, greater homework adherence was significantly associated with greater response and remission from depression in the first and last 8 sessions of CBT. Our results suggest that homework adherence can account for response and remission early and late in treatment, with adequate session attendence.
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Coryell W. Impact, Diagnosis, Phenomenology, and Biology. Handb Exp Pharmacol 2019; 250:3-33. [PMID: 31004226 DOI: 10.1007/164_2018_156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This section provides summaries of the epidemiology, phenomenology, nosology, and the suspected biological substrates of the depressive disorders. It particularly emphasizes the historical evolution of the pertinent diagnostic constructs and the prognostic import both of the various diagnostic groupings and of the individual symptoms and symptom clusters.
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Affiliation(s)
- William Coryell
- Department of Psychiatry, Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA.
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The potential of predictive analytics to provide clinical decision support in depression treatment planning. Curr Opin Psychiatry 2018; 31:32-39. [PMID: 29076894 DOI: 10.1097/yco.0000000000000377] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To review progress developing clinical decision support tools for personalized treatment of major depressive disorder (MDD). RECENT FINDINGS Over the years, a variety of individual indicators ranging from biomarkers to clinical observations and self-report scales have been used to predict various aspects of differential MDD treatment response. Most of this work focused on predicting remission either with antidepressant medications versus psychotherapy, some antidepressant medications versus others, some psychotherapies versus others, and combination therapies versus monotherapies. However, to date, none of the individual predictors in these studies has been strong enough to guide optimal treatment selection for most patients. Interest consequently turned to decision support tools made up of multiple predictors, but the development of such tools has been hampered by small study sample sizes. Design recommendations are made here for future studies to address this problem. SUMMARY Recommendations include using large prospective observational studies followed by pragmatic trials rather than smaller, expensive controlled treatment trials for preliminary development of decision support tools; basing these tools on comprehensive batteries of inexpensive self-report and clinical predictors (e.g., self-administered performance-based neurocognitive tests) versus expensive biomarkers; and reserving biomarker assessments for targeted studies of patients not well classified by inexpensive predictor batteries.
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Dunlop BW, Rajendra JK, Craighead WE, Kelley ME, McGrath CL, Choi KS, Kinkead B, Nemeroff CB, Mayberg HS. Functional Connectivity of the Subcallosal Cingulate Cortex And Differential Outcomes to Treatment With Cognitive-Behavioral Therapy or Antidepressant Medication for Major Depressive Disorder. Am J Psychiatry 2017; 174:533-545. [PMID: 28335622 PMCID: PMC5453828 DOI: 10.1176/appi.ajp.2016.16050518] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The purpose of this article was to inform the first-line treatment choice between cognitive-behavioral therapy (CBT) or an antidepressant medication for treatment-naive adults with major depressive disorder by defining a neuroimaging biomarker that differentially identifies the outcomes of remission and treatment failure to these interventions. METHOD Functional MRI resting-state functional connectivity analyses using a bilateral subcallosal cingulate cortex (SCC) seed was applied to 122 patients from the Prediction of Remission to Individual and Combined Treatments (PReDICT) study who completed 12 weeks of randomized treatment with CBT or antidepressant medication. Of the 122 participants, 58 achieved remission (Hamilton Depression Rating Scale [HAM-D] score ≤7 at weeks 10 and 12), and 24 had treatment failure (<30% decrease from baseline in HAM-D score). A 2×2 analysis of variance using voxel-wise subsampling permutation tests compared the interaction of treatment and outcome. Receiver operating characteristic curves constructed using brain connectivity measures were used to determine possible classification rates for differential treatment outcomes. RESULTS The resting-state functional connectivity of the following three regions with the SCC was differentially associated with outcomes of remission and treatment failure to CBT and antidepressant medication and survived application of the subsample permutation tests: the left anterior ventrolateral prefrontal cortex/insula, the dorsal midbrain, and the left ventromedial prefrontal cortex. Using the summed SCC functional connectivity scores for these three regions, overall classification rates of 72%-78% for remission and 75%-89% for treatment failure was demonstrated. Positive summed functional connectivity was associated with remission with CBT and treatment failure with medication, whereas negative summed functional connectivity scores were associated with remission to medication and treatment failure with CBT. CONCLUSIONS Imaging-based depression subtypes defined using resting-state functional connectivity differentially identified an individual's probability of remission or treatment failure with first-line treatment options for major depression. This biomarker should be explored in future research through prospective testing and as a component of multivariate treatment prediction models.
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Affiliation(s)
- Boadie W. Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Justin K. Rajendra
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - W. Edward Craighead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
- Department of Psychology, Emory University, Atlanta, GA, USA
| | - Mary E. Kelley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Callie L. McGrath
- Department of Psychiatry, Harvard Medical School and McLean Hospital, Belmont, MA
| | - Ki Sueng Choi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Becky Kinkead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Charles B. Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Helen S. Mayberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Abstract
The history and present status of the definition, prevalence, neurobiology, and treatment of atypical depression (AD) is presented. The concept of AD has evolved through the years, and currently, in Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, the specifier of depressive episode with atypical feature is present for both diagnostic groups, that is, depressive disorders and bipolar and related disorders. This specifier includes mood reactivity, hyperphagia, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity. Prevalence rates of AD are variable, depending on the criteria, methodology, and settings. The results of epidemiological studies using DSM criteria suggest that 15%-29% of depressed patients have AD, and the results of clinical studies point to a prevalence of 18%-36%. A relationship of AD with bipolar depression, seasonal depression, and obesity has also been postulated. Pathogenic research has been mostly focused on distinguishing AD from melancholic depression. The differences have been found in biochemical studies in the areas of hypothalamic-pituitary-adrenal axis, inflammatory markers, and the leptin system, although the results obtained are frequently controversial. A number of findings concerning such differences have also been obtained using neuroimaging and neurophysiological and neuropsychological methods. An initial concept of AD as a preferentially monoamine oxidase inhibitor-responsive depression, although confirmed in some further studies, is of limited use nowadays. Currently, despite numerous drug trials, there are no comprehensive treatment guidelines for AD. We finalize the article by describing the future research perspectives for the definition, neurobiology, and treatment. A better specification of diagnostic criteria and description of clinical picture, a genome-wide association study of AD, and establishing updated treatment recommendations for this clinical phenomenon should be the priorities for the coming years.
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Affiliation(s)
| | - Janusz K Rybakowski
- Department of Adult Psychiatry.,Department of Child and Adolescent Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
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Dunlop BW. Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2016; 14:156-173. [PMID: 31975799 PMCID: PMC6519650 DOI: 10.1176/appi.focus.20150042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.
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Affiliation(s)
- Boadie W Dunlop
- Dr. Dunlop is with the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia (e-mail: )
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