Differences between chronic and nonchronic depression: Systematic review and implications for treatment

Schema therapy versus treatment as usual for outpatients with difficult-to-treat depression: study protocol for a parallel group randomized clinical trial (DEPRE-ST)

BACKGROUND

About one third of patients with depression are in a condition that can be termed as "difficult-to-treat". Some evidence suggests that difficult-to-treat depression is associated with a higher frequency of childhood trauma and comorbid personality disorders or accentuated features. However, the condition is understudied, and the effects of psychotherapy for difficult-to-treat depression are currently uncertain. The aim of this trial is to investigate the beneficial and harmful effects of 30 sessions of individual schema therapy versus treatment as usual for difficult-to-treat depression in the Danish secondary, public mental health sector.

METHODS

In this randomized, multi-centre, parallel-group, superiority clinical trial, 129 outpatients with difficult-to-treat depression will be randomized (1:1) to 30 sessions of individual schema therapy or treatment as usual; in this context mainly group-based, short-term cognitive behaviour or psychodynamic therapy. The primary outcome is the change from baseline in depressive symptoms 12 months after randomization, measured on the observer-rated 6-item Hamilton Rating Scale for Depression. The secondary outcomes are health-related quality of life assessed with the European Quality of Life 5 Dimensions 5 Level Version, functional impairment assessed with the Work and Social Adjustment Scale, psychological wellbeing assessed with the WHO-5 Well-being Index, and negative effects of treatment assessed with the Negative Effects Questionnaire. Exploratory outcomes are improvement on patient self-defined outcomes, personal recovery, anxiety symptoms, anger reactions, metacognitive beliefs about anger, and perseverative negative thinking. Outcomes will be assessed at 6, 12, and 24 months after randomization; the 12-month time-point being the primary time-point of interest. Outcome assessors performing the depression-rating, data managers, statisticians, the data safety and monitoring committee, and conclusion makers for the outcome article will be blinded to treatment allocation and results. To assess cost-effectiveness of the intervention, a health economic analysis will be performed.

DISCUSSION

This trial will provide evidence on the beneficial and harmful effects, as well as the cost-effectiveness of schema therapy versus treatment as usual for outpatients with difficult-to-treat depression. The results can potentially improve treatment for a large and understudied patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833087. Registered on 15th April 2023 (approved without prompts for revision on 27th April 2023).

Threat experiences moderate the link between hippocampus volume and depression symptoms prospectively in adolescence

Identifying neuroimaging risk markers for depression has been an elusive goal in psychopathology research. Despite this, smaller hippocampal volume has emerged as a potential risk marker for depression, with recent research suggesting this association is moderated by family income. The current pre-registered study aimed to replicate and extend these findings by examining the moderating role of family income and three dimensions of environmental experience on the link between hippocampus volume and later depression. Data were drawn from the Adolescent Brain Cognitive Development (ABCD) study and were comprised of 6693 youth aged 9-10 years at baseline. Results indicated that psychosocial threat moderated the association between right hippocampus volume and depression symptoms two years later, such that a negative association was evident in low-threat environments (std. beta=0.15, 95% CI [0.05, 0.24]). This interaction remained significant when baseline depression symptoms were included as a covariate, though only in youth endorsing 1 or more depression symptoms at baseline (β = 0.13, 95% CI = [0.03, 0.22]). These results suggest that hippocampus volume may not be a consistent correlate of depression symptoms in high risk environments and emphasize the importance of including measures of environmental heterogeneity when seeking risk markers for depression.

Profiles of interpersonal relationship qualities and trajectories of internalizing problems among Chinese adolescents

Adolescence is a significant period for the formation of relationship networks and the development of internalizing problems. With a sample of Chinese adolescents (N = 3,834, 52.01% girls, Mage = 16.68 at Wave 1), the present study aimed to identify the configuration of adolescents' relationship qualities from four important domains (i.e., relationship quality with mother, father, peers, and teachers) and how distinct profiles were associated with the development of internalizing problems (indicated by depressive and anxiety symptoms) across high school years. Latent profile analysis identified a five-profile configuration with four convergent profiles (i.e., relationship qualities with others were generally good or bad) and one "Father estrangement" profile (i.e., the relationship quality with others were relatively good but that with father was particularly poor). Further conditional latent growth curve analysis indicated the "Father estrangement" profile was especially vulnerable to an increase in the internalizing problems as compared with other relationship profiles. This study contributes to understanding the characteristics of interpersonal relationship qualities and their influences on adolescent internalizing problems in a non-Western context. Results were further discussed from a culturally specific perspective.

Current and past depression as risk factors for incident type 2 diabetes mellitus and pre-diabetes in men and women: evidence from a longitudinal community cohort

BACKGROUND

Depression is associated with an increased risk for type 2 diabetes mellitus. However, depression may take different courses, and it is not fully understood how these affect the development of diabetes. It is further to be determined whether sex modifies the association between depression and type 2 diabetes.

METHODS

We analyzed data from the Gutenberg Health Study, a longitudinal and population-based cohort study (N = 15,010) in Germany. Depressive symptoms (measured by PHQ-9), history of depression, diabetes mellitus, and relevant covariates were assessed at baseline, and the outcomes of prediabetes and type 2 diabetes mellitus were evaluated 5 years later. Logistic regression was used to estimate odds ratios of incident prediabetes and type 2 diabetes mellitus, adjusting for potential confounders as identified in a Directed Acyclic Graph.

RESULTS

In the confounder adjusted model, current depression (PHQ-9 ≥ 10 at baseline; OR = 1.79, 95% CI = 1.11 to 2.74, p = 0.011), and persistent depression had a statistically significant (OR = 2.44, 95% CI = 1.62 to 3.54, p = 0.005) effect on incident type 2 diabetes mellitus. A history of depression without current depression had no statistically significant effect on type 2 diabetes (OR = 1.00, 95% CI = 0.68 to 1.43, p = 0.999). The effect of depression on incident diabetes did not differ significantly between women (OR = 2.02; 95% CI = 1.32 to 3.09) and men (OR = 2.16; 95% CI = 1.41 to 3.31; p-value for interaction on the multiplicative scale p = 0.832 and on the additive scale p = 0.149). Depression did not have a significant effect on incident prediabetes.

CONCLUSION

This study shows how the history and trajectory of depression shape the risk for diabetes. This raises interesting questions on the cumulative effects of depression trajectories on diabetes and body metabolism in general. Depression can negatively affect physical health, contributing to increased morbidity and mortality in people with mental disorders.

Depressive Symptoms, the Impact on ART Continuation, and Factors Associated with Symptom Improvement Among a Cohort of People Living with HIV in British Columbia, Canada

Depressive symptoms among people living with HIV (PLWH) are associated with poorer overall health outcomes. We characterized depressive symptoms and improvements in symptomology among PLWH (≥ 19 years old) in British Columbia (BC), Canada. We also examined associations between depressive symptomology and antiretroviral therapy (ART) treatment interruptions. Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10), within a longitudinal cohort study with three surveys administered 18-months apart. We used multivariable logistic regression to model factors associated with improvements in depressive symptoms (CES-D-10 scores from ≥ 10 to < 10). Of the 566 participants eligible for analysis 273 (48.2%) had CES-D scores indicating significant depressive symptoms (score ≥ 10) at enrollment. Improvements in symptoms at first follow-up were associated with greater HIV self-care on the Continuity of Care Scale (adjusted odds ratio: 1.17; 95% CI 1.03-1.32), and not having a previously reported mental health disorder diagnosis (aOR 2.86; 95% CI 1.01-8.13). Those reporting current cocaine use (aOR 0.33; 95% CI 0.12-0.91) and having a high school education, vs. less than, (aOR 0.25; 95% CI 0.08-0.82) had lower odds of improvement in depressive symptomatology. CES-D scores ≥ 10 were not significantly associated with ART treatment interruptions during follow-up (aOR: 1.08; 95% CI:0.65-1.8). Supporting greater self-care and consideration of mental health management strategies in relation to HIV may be useful in promoting the wellbeing of PLWH who experience depressive symptoms.

Suicidal behaviors and adverse childhood experiences: A cross-diagnostic study in persistent depressive disorder and borderline personality disorder

Adverse childhood experiences (ACE) constitute a known risk factor for suicidality. There is a research gap regarding differential patterns of associations between variants of suicidal ideations and behaviors (SIB) and characteristics of ACE in severe mental disorders. This cross-diagnostic study investigates whether SIB are related to ACE subtypes in two high-risk conditions, i.e., persistent depressive disorder (PDD) and borderline personality disorder (BPD). Inpatients with PDD (n = 117; age 40.2 years ± 12.3) and BPD (n = 74; age 26.2 ± 7.9) were assessed with the Columbia-Suicide Severity Rating Scale for suicidal ideations (SI), suicidal behaviors (SB) and actual suicide attempts (SA); ACE were recorded with the Childhood Trauma Questionnaire. In PDD, SI and SA were associated with childhood physical abuse (ORs 7.2 and 2.3, respectively). In BPD, SA were associated with severe experiences of physical abuse (OR 6.5). Weaker yet significant associations were found for childhood emotional abuse in PDD with SB (including SA), and in BPD with SA. Recall of childhood physical abuse may be clinically relevant information for identifying particular risks of SIB. Future studies should investigate these differential patterns in more depth and in terms of causality.

Efficacy and acceptability of third-wave psychotherapies in the treatment of depression: a network meta-analysis of controlled trials

Introduction

In recent decades, various new psychotherapy approaches have been developed in an effort to overcome issues of non-response, referred to as "third-wave psychotherapies." How third-wave therapies perform in comparison to each other, to classical CBT, or other common comparators in the treatment of depression has not yet been systematically assessed.

Methods

We firstly determined the scope of the term "third-wave" by conducting a systematic search. The identified approaches were then used as search terms for the systematic review and network meta-analysis (NMA). We searched MEDLINE, CENTRAL, PsychINFO and Web of Science from inception until 31 July 2022. We assessed randomized controlled trials comparing third-wave psychotherapies to each other, CBT, treatment as usual (TAU), medication management, active control conditions, or waitlist (WL) in adult populations with depressive disorders. The treatments included were acceptance and commitment therapy, behavioral activation, cognitive behavioral analysis system of psychotherapy, dialectical behavioral therapy, mindfulness-based cognitive therapy, meta-cognitive therapy, positive psychotherapy and schema therapy. The primary outcome was depression severity (efficacy) at study endpoint, and the secondary outcome was all-cause discontinuation (acceptability). This review was registered in PROSPERO, identifier CRD42020147535.

Results

Of 7,971 search results, 55 trials were included in our NMA (5,827 patients). None of the third-wave therapies were more efficacious than CBT but most were superior to TAU [standardized mean differences (SMD) ranging between 0.42 (95% CI -0.37; 1.19) and 1.25 (0.48; 2.04)]. Meta-cognitive therapy (MCT) was more efficacious than three other third-wave therapy approaches. None of the third-wave treatments were more acceptable than WL or CBT. Twenty-seven percent of the trials were rated as low risk of bias. Confidence in the evidence was largely low according to GRADE. Inconsistency emerged for a small number of comparisons.

Interpretations

Third-wave therapies are largely efficacious and acceptable alternatives to CBT when compared to TAU, with few differences between them. The evidence so far does not point toward superiority or inferiority over CBT. Patient-level research may offer possibilities for tailoring individual psychotherapies to the needs of individual patients and future trials should make this data available. The evidence base needs to be broadened by sufficiently powered trials.

Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity

The COVID-19 pandemic may widen the disparities in access to behavioral health (BH) services among groups that have been historically marginalized. However, the rapid expansion of telehealth presents an opportunity to reduce these disparities. The objective was to assess the impact of COVID-19 on BH visits, including in-person and telehealth, and BH treatments by different race and ethnicity groups. This was a retrospective, observational study using administrative claim data. Two cohorts were created: a before-COVID-19 group and a during-COVID-19 group. A difference-in-differences analysis was conducted to assess the access to BH-related visits between the 2 groups by different race and ethnicity groups. The study sample included 90,268 patients aged 18 to 64 years with repeated BH diagnoses in baseline periods and continuous medical and pharmacy enrollment. During the pandemic, BH telehealth visits surged, whereas the overall utilization of BH services, mental health medication, and counseling declined among all racial groups as the BH telehealth increase did not fully compensate for the reduction of in-person visits. Latino patients had a higher likelihood of using BH telehealth visits than White patients. However, Black patients had a lower likelihood of using substance use disorder (SUD) treatment than their White counterparts. Our results also suggested that care continuation and pre-established care-seeking behaviors are associated with increasing BH visits and treatments. As policy makers and payers are expanding offerings of telehealth visits, it is imperative to do so through a health equity lens and center the needs of groups that have been economically and socially marginalized to advance equitable adoption of telehealth.

The Effectiveness of an Intensive Inpatient Psychotherapy Program for Chronic Depression: A naturalistic comparison with wait list

BACKGROUND

Patients with chronic depression (CD) typically have an early symptom onset, more psychiatric comorbidities, more treatment attempts, and more frequent and longer inpatient hospitalizations than patients with major depressive disorders. The main purpose of this study was to investigate the effectiveness of an intensive inpatient psychotherapy program for patients with chronic depression (CD). The primary research question was whether two intensive psychodynamic inpatient treatments, affect phobia therapy (APT) and VITA, were superior to an outpatient wait list condition, receiving treatment as usual (TAU), at completion of treatment. To investigate if a potential difference between the intensive treatment and the wait list control group was dependent on a specific psychotherapeutic model, the study contrasted two therapies with similar intensity, but different theoretical rationales.

METHODS

Two hundred eighty patients with CD were included in a naturalistic study. Patients were assessed at four time points; assessment, start of therapy, end of therapy and 1-year follow-up. Three comparisons were performed with patients matched across groups; Intensive inpatient treatment program (APT + VITA) vs wait list during treatment, APT vs VITA during treatment and APT vs VITA during follow-up. The outcome measure was the BDI-II.

RESULTS

Intensive inpatient treatment program vs. wait list showed a significant difference in favor of the intensive treatment. No significant differences were found between APT and VITA during therapy or follow-up; but both groups had large effect sizes during treatment, which were maintained during follow-up.

CONCLUSIONS

The intensive inpatient psychotherapy program showed superior effect on chronic depression over an outpatient wait list condition receiving treatment as usual (TAU), but no significant differences were found between the two intensive inpatient psychodynamic treatments. The results provide support for the effectiveness of an intensive inpatient psychotherapy program in treatment of chronic and severe disorders, such as CD, which could be of benefit for policymakers and the health care sector as they are allocating recourses efficiently.

TRIAL REGISTRATION

This study has been retrospectively registered on ClinicalTrials.gov (NCT05221567) on February 3rd, 2022.

Suicidal behaviors are associated with loneliness and decrease during inpatient CBASP treatment for persistent depressive disorder

Suicidal ideation and behavior (SIB) are common in persistent depressive disorder (PDD) and may be related to interpersonal dysfunction. While SIB has been extensively analyzed in other high-risk disorders (e.g., borderline personality disorder, BPD), data on interpersonal risk factors and effects of specific psychotherapy on SIB in PDD are limited. This study aimed at investigating loneliness versus social network size as interpersonal risk factors for SIB in PDD and assess effects of cognitive behavioral analysis system of psychotherapy (CBASP) on this domain. In a prospective naturalistic study, 64 PDD patients were assessed, who underwent a 10-weeks inpatient CBASP program. Our clinical comparison group consisted of 34 BPD patients, who underwent a 10-weeks inpatient dialectical behavioral therapy (DBT) program. SIB was measured with the Columbia-Suicide Severity Rating Scale (C-SSRS), loneliness and social network size with the UCLA Loneliness Scale (UCLA) and the Social Network Index (SNI). Twenty-six PDD patients (40.6% of the PDD sample) showed current SIB at baseline in comparison with 26 BPD patients (76.5% of the BPD sample). While in suicidal PDD patients, SIB was associated with perceived social isolation (UCLA), but not with reduced social network size (SNI), this association was not observed in suicidal BPD patients. In PDD, SIB significantly decreased during CBASP. In conclusion, SIB appears to be associated with interpersonal factors related to loneliness in PDD, but not in BPD. CBASP showed first positive evidence in reducing SIB in PDD, but our pilot data need replication studies.

Family involvement in psychotherapy for depression in children and adolescents: Systematic review and meta-analysis

PURPOSE

Depressive disorders in children and adolescents have an enormous impact on their general quality of life. There is a clear need to effectively treat depression in this age group. Effects of psychotherapy can be enhanced by involving caregivers. In our systematic review and meta-analysis, we examine for the first time the effects of caregiver involvement in depression-specific interventions for children and adolescents.

METHODS

We included randomized controlled trials examining the effects of interventions for children and adolescents with depression involving their caregivers or families compared to interventions without including caregivers. Primary outcome was the severity of childhood and adolescent depression.

RESULTS

Overall, 19 randomized controlled trials could be included (N = 1553) that were highly heterogeneous regarding outcome measures or the extent of caregiver integration. We were able to include k = 17 studies in our meta-analysis and find a small but significant effect for family-involved interventions against active control conditions without family-involvement at post intervention (α = 0.05, d = 0.34; [0.07; 0.60]; p = .01).

CONCLUSIONS

We detected an overall significant but small effect of family/caregivers' involvement compared to control groups without it. Structured, guideline-based research is urgently needed to identify for which children/adolescents with depression, under what circumstances, and in what form the family should be effectively involved in their psychotherapy.

Investigating the feasibility and effectiveness of a modular treatment program for children and adolescents with depression and interpersonal problems: study protocol of a quasi-experimental pilot feasibility trial (CBASP@YoungAge)

BACKGROUND

Depression is a serious disorder in childhood and adolescence. Affected children and adolescents show significant impairments in various aspects of life. Studies on the effectiveness or efficacy of psychotherapy in depressed children and adolescents are qualitatively very heterogeneous and reveal small effect sizes. There is thus a need to better tailor psychotherapy approaches to these age groups to improve outcomes like parent-child relationship, symptomatology, or quality of life. To address this gap, we designed a modular, individualized treatment program for children and adolescents based on the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) including caregiver involvement.

METHOD

This quasi-experimental pilot feasibility trial is a phase 1 to phase 2 study investigating the feasibility and effectiveness of CBASP@YoungAge by including an intervention group (CBASP@YoungAge) and a treatment-as-usual control group. The treatment of depressive symptoms as well as interpersonal problems with primary caregivers are the main targets of CBASP@YoungAge. Personalization is ensured concerning the treatment course, caregivers' involvement, and the patient's age. The primary outcome relates to two areas: the feasibility of the CBASP@YoungAge treatment program in an outpatient context and a change in patients' depressive symptomatology from before to after treatment. We conduct a brief process evaluation after each session in the intervention group to closely monitor the treatment process and examine feasibility from the therapists' and patients' perspectives and mechanisms of symptom change. In addition, we consider interpersonal behavior between children and caregivers, parenting behavior, and monitor the global-health-index in children and parents as secondary outcomes. Pre-, post-, and follow-up data are evaluated.

DISCUSSION

This is the first study of a modular-based intervention program for children and adolescents with depression and a clear focus on the interpersonal problems between the depressed young patient and her/his caregiver. It will provide important knowledge on the feasibility and effectiveness of the program and potential benefits of including caregivers in psychotherapy. Based on this study's results, we plan a multicenter, randomized, controlled trial whose long-term aim is to improve the psychotherapeutic care of young patients with depression while preventing persistent courses of depressive disorders.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS (identifier DRKS00023281 ). Registered 17 November 2020-Retrospectively registered.

Treatment of difficult-to-treat depression - clinical guideline for selected interventions

BACKGROUND

Difficult-to-treat-depression (DTD) is a clinical challenge. The interventions that are well-established for DTD are not suitable or effective for all the patients. Therefore, more treatment options are highly warranted. We formulated an evidence-based guideline concerning six interventions not well-established for DTD in Denmark.

METHODS

Selected review questions were formulated according to the PICO principle with specific definitions of the patient population (P), the intervention (I), the comparison (C), and the outcomes of interest (O), and systematic literature searches were performed stepwise for each review question to identify relevant systematic reviews/meta-analyses, and randomized controlled trials. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the methodological quality of the included studies. Clinical recommendations were formulated based on the evidence, the risk-benefit ratio, and perceived patient preferences.

RESULTS

We found sufficient evidence for a weak recommendation of repetitive transcranial magnetic stimulation (rTMS) and cognitive behavioural analysis system of psychotherapy (CBASP). The use of bright light therapy in DTD was not sufficiently supported by the evidence, but should be considered as good clinical practice. The interventions should be considered in addition to ongoing antidepressant treatment. We did not find sufficient evidence to recommend intravenous ketamine/esketamine, rumination-focused psychotherapy, or cognitive remediation to patients with DTD.

CONCLUSION

The evidence supported two of the six reviewed interventions, however it was generally weak which emphasizes the need for more good quality studies. This guideline does not cover all treatment options and should be regarded as a supplement to relevant DTD-guidelines.

Chronic vs non-chronic depression in psychiatric inpatient care - Data from a large naturalistic multicenter trial

BACKGROUND

Around 20% - 30% of depressed individuals experience a chronic form of depression lasting two or more years. This naturalistic study investigates the characteristics and the course of chronic depressed patients (CD) during standard antidepressant treatment in comparison to not chronically depressed (NCD) patients.

METHODS

Data of 954 patients were drawn from the prospective naturalistic, multicenter study of the German research network on depression, CD was met as classifier by 113 patients (11.8%), whereas 841 patients (88.2%) had non-chronic courses (NCD).

RESULTS

CD was significantly associated with a low age at onset, use of benzodiazepines, psychotherapy at baseline, substance abuse, a depressive personality disorder and a low degree of extraversion. CD patients showed a longer hospital stay, lower remission rates, increased rates of suicidal ideation as well as higher depression scores at discharge. In addition, individuals with chronic depression continued to obtain higher neuroticism scores and lower extraversion scores at discharge.

LIMITATION

Results were assessed by a post-hoc analysis, based on prospectively collected data.

CONCLUSION

CD patients have an inferior outcome in clinical measures as well as personality dimensions (i.e. low extraversion) compared to non-CD patients. These findings support the notion that CD patients entering a setting of standard psychiatric inpatient care will show less benefit compared to non-CD patients, and that this difference as such may be used as a stratifying marker for providing specialized psychiatric treatment with optimized pharmacological and psychotherapeutic protocols.

Failure to resolve loss and compromised mentalizing in female inpatients with major depressive disorder

Attachment and mentalizing are central concepts in research on the etiology, course, and treatment of depression. The goal of this cross-sectional study was to clarify the unique value of these constructs in characterizing the presence, severity, and chronicity of depression. We examined 50 female inpatients suffering from Major Depressive Disorder (MDD) in comparison to 47 matched healthy controls regarding their attachment states of mind, mentalizing capacities, and clinical variables indicating depression severity and chronicity (e.g. illness duration, number of hospitalizations). In the group of depressed patients, unresolved attachment with regard to loss was significantly overrepresented. Dimensionally, patients were more disorganized and more insecure, whereas there was no difference on the dismissing-preoccupied dimension between the two groups. Mentalizing was significantly lower in patients than in healthy controls. Logistic regression analysis revealed attachment insecurity, mentalizing deficits, and unresolved loss to be incrementally relevant to predict MDD. Correlations with clinical parameters in the group of depressed patients showed positive associations between mentalizing deficits, attachment insecurity, and variables indicating illness chronicity. Our findings highlight the relevance of the inability to resolve or reappraise loss experiences in depressive states.

Adding an app-based intervention to the Cognitive Behavioral Analysis System of Psychotherapy (CBASP): Proof-of-Concept in Routine Outpatient Psychotherapy Treatment (Preprint)

Background

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is an empirically supported psychotherapeutic treatment developed specifically for persistent depressive disorder. However, given the high rates of nonresponse and relapse, there is a need for optimization. Studies suggest that outcomes can be improved by increasing the treatment dose via, for example, the continuous web-based application of therapy strategies between sessions. The strong emphasis in CBASP on the therapeutic relationship, combined with limited therapeutic availabilities, encourages the addition of web-based interventions to face-to-face therapy in terms of blended therapy.

Objective

The aim of this study was to test an app-based intervention called CBASPath, which was designed to be used as a blended therapy tool. CBASPath offers 8 sequential modules with app-based exercises to facilitate additional engagement with the therapy content and a separate exercise to conduct situational analyses within the app at any time.

Methods

CBASPath was tested in an open pilot study as part of routine outpatient CBASP treatment. Participating patients were asked to report their use patterns and blended use (integrated use of the app as part of therapy sessions) at 3 assessment points over the 6-month test period and rate the usability and quality of and their satisfaction with CBASPath.

Results

The results of the pilot trial showed that 93% (12/13) of participants used CBASPath as a blended tool during their therapy and maintained this throughout the study period. Overall, they reported good usability and quality ratings along with high user satisfaction. All participants showed favorable engagement with CBASPath; however, the frequency of use differed widely among the participants and assessment points. Situational analysis was used by all participants, and the number of completed modules ranged from 1 to 7. All participants reported blended use, although the frequency of integration in the face-to-face sessions varied widely.

Conclusions

Our findings suggest that the digital augmentation of complex and highly interactive CBASP therapy in the form of blended therapy with CBASPath is feasible in routine outpatient care. Therapeutic guidance might contribute to high adherence and increase patient self-management. A few adjustments, such as saving entries directly in the app, could facilitate higher user engagement. A randomized controlled trial is now needed to investigate the efficacy and added value of this blended approach. In the long term, CBASPath could help optimize persistent depressive disorder treatment and reduce relapse by intensifying therapy and providing long-term patient support through the app.

Evaluation of Android and Apple Store Depression Applications Based on Mobile Application Rating Scale

There are a large number of mobile applications that allow the monitoring of health status. The quality of the applications is only evaluated by users and not by standard criteria. This study aimed to examine depression-related applications in major mobile application stores and to analyze them using the rating scale tool Mobile Application Rating Scale (MARS). A search of digital applications for the control of symptoms and behavioral changes in depression was carried out in the two reference mobile operating systems, Apple (App Store) and Android (Play Store), by means of two reviewers with a blind methodology between September and October 2019 in stores from Spain and the United Kingdom. Eighteen applications from the Android Play Store and twelve from the App Store were included in this study. The quality of the applications was evaluated using the MARS scale from 1 (inadequate) to 5 (excellent). The average score of the applications based on the MARS was 3.67 ± 0.53. The sections with the highest scores were “Functionality” (4.51) and “Esthetics” (3.98) and the lowest “Application Subjective quality” (2.86) and “Information” (3.08). Mobile Health applications for the treatment of depression have great potential to influence the health status of users; however, applications come to the digital market without health control.

A multi-method assessment of attentional processes in chronic, treatment-resistant depression

Attentional deficits as well as attentional biases towards negative material are related to major depression and might maintain chronicity. However, studies investigating attentional deficits and attentional biases in chronic, treatment-resistant depressed are lacking. The aim of the current study was to compare measures of attentional deficits and attentional bias between chronic, treatment-resistant depressed outpatients and never-depressed control participants. Attentional deficits were assessed with the attentional control scale (ACS) and the Stroop Color naming task. Attentional bias was measured with the exogenous cueing task (ECT) and an emotional Stroop task. Chronic, treatment-resistant depressed patients (n = 80) showed significantly more attentional deficits than never-depressed controls (n = 113) on the ACS and Stroop color-naming task. However, in contrast with hypotheses, no differences were found between chronic, treatment-resistant depressed patients and never-depressed individuals on the ECT or emotional Stroop task. The current findings indicate that chronic, treatment-resistant depressed patients present attentional deficits. The results however question whether this patient group shows attentional biases for negative material. Future research should include comparisons of chronic, treatment-resistant and non-chronically depressed patients. If replicated, these current results might indicate that focusing on improving attentional deficits could be a more promising target for treatment than addressing attentional biases.

Correlates and Predictors of Chronicity among Adolescents Living in Puerto Rico With a History of Depressive Symptoms

Chronic depression (CD) among Hispanic/Latina(o) youths has been understudied, although chronicity is the biggest risk factor for treatment-resistant depression. We examined CD correlates and predictors among 291 youths (aged 12-18 years) living in Puerto Rico with a history of depressive symptoms. They completed the Children's Depression Inventory (CDI), the Depressive Symptoms Spectrum Assessment Inventory (DSSAI), and the Brief Structured Diagnostic Measure for Depression. We explored CD correlates using Odds Ratios adjusted for CDI-Total scores. With multiple logistic regression, we identified optimal predictors of a history of chronic depressive symptoms (HCDS) or any chronic depressive disorder (HACDD). Living zone (rural), history of depressive disorder, household size (< 4), age of onset of symptoms (< 13 years), death/suicidal thoughts at the first episode, antidepressants use, and scores ≥ 84^th percentile in the DSSAI-Anhedonia subscale, accounted for 37% of HCDS variance. The latter five variables and socioeconomic status (lower-middle/low) best distinguished HACDD and episodic disorders (R ² = .331). Identifying factors that distinguish chronic and episodic depression among Hispanic/Latina(o) youths may help to improve their diagnosis, access to and quality of care, as well as treatment selection, tailoring, and outcomes.

Cognitive Behavioral Analysis System of Psychotherapy for inpatients with persistent depressive disorder: a naturalistic trial on a general acute psychiatric unit

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was originally developed for outpatients with persistent depressive disorder (PDD). We adapted CBASP as inpatient treatment on a general acute psychiatric ward and evaluated its outcome and feasibility. Sixty PDD patients received a 12-week multidisciplinary CBASP program. Hamilton Depression Rating Scale (HAMD₂₄) and Beck Depression Inventory (BDI-II) served as primary and secondary outcome measures. Childhood maltreatment at baseline and change in interpersonal distress from pre to post were investigated as predictors of treatment outcome. A 6-month follow-up assessment was conducted. Feasibility was assessed through dropouts and satisfaction with the program. Fifty patients completed the program (16.7% dropouts). An ANOVA with three repeated measurements (pre, post, FU) in the ITT sample revealed a main effect of time. For the primary outcome, depressive symptoms decreased from pre (28.3) to post (11.5, response rate: 72.7%, d = 1.8), and from pre to FU (13.9, d = 1.2). Four patients relapsed. The secondary outcome confirmed the results; however, the response rate was lower (BDI-II: 31.7%, pre to post: d = 0.8, pre to FU: d = 0.3), and ten patients relapsed at FU. Reduction in interpersonal distress, but not childhood maltreatment, predicted BDI-II response. Key limitations of this naturalistic open trial are the lack of a comparison group and non-blinded HAMD₂₄ ratings. Inpatient CBASP for PDD appears feasible on a general acute psychiatric ward with effect sizes comparable to specialized psychotherapy wards and to the outpatient setting.

Do self-criticism and somatic symptoms play a key role in chronic depression? Exploring the factor structure of Beck depression inventory-II in a sample of chronically depressed inpatients

BACKGROUND

The factor structure of depression differs for different sub-samples. The purpose of this study was to explore the factor structure of Beck Depression Inventory-II in patients with chronic depression presenting for inpatient treatment.

METHODS

Using exploratory structural equation modeling (ESEM), we explored whether a two-factor solution or a bifactor solution provided best model fit for a sample of 377 patients. For the best fitting model stability was assessed with tests for invariance across primary diagnosis (persistent depressive disorder v. recurrent major depressive disorder), and presence of comorbidity.

RESULTS

A bifactor solution with one general factor and two specific factors provided best model fit. Invariance analyses provided support for measurement invariance and stability of the factor solution.

LIMITATIONS

The naturalistic study design implies some uncertainty regarding possible systematic differences between the patients on demographic and clinical characteristics.

CONCLUSION

The factor structure in our sample was best explained by a general depression factor, one specific factor pertaining to self-criticism, and one consisting of the somatic items fatigue, disturbance of sleep, and appetite. Clinicians could benefit from paying special attention to the subfactors identified, as these findings may have implications for treatment choice for patients with chronic depression.

Borderline Personality Features in Patients With Persistent Depressive Disorder and Their Effect on CBASP Outcome

Introduction: The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was developed for the treatment of persistent depressive disorder (PDD), where comorbid personality disorders (PD) are common. In contrast to other PD, comorbid borderline personality disorder (BPD) is often regarded as an exclusion criterion for CBASP. In clinical settings, however, subthreshold BPD symptoms are prevalent in PDD and may not be obvious at an initial assessment prior to therapy. As data on their impact on CBASP outcome are very limited, this naturalistic study investigates BPD features in PDD and their relevance for the therapeutic outcome of a multimodal CBASP inpatient program. Method: Sixty patients (37 female, mean age 38.3, SD 11.9 years) meeting DSM-5 criteria for PDD underwent a 10 weeks CBASP inpatient program. BPD features (i.e., number of fulfilled DSM-5 criteria) together with childhood maltreatment and rejection sensitivity were assessed on admission. Before and after treatment, severity of depressive symptoms was measured using the Montgomery-Asberg Depression Rating Scale (MADRS) and the Beck Depression Inventory (BDI-II). BPD symptoms were assessed using the Borderline Personality Disorder Severity Index (BPDSI-IV) and the Borderline Symptom List (BSL-23). Intercorrelations of baseline characteristics and symptom change during treatment were analyzed. Results: Patients with PDD met a mean of 1.5 (SD 1.6) BPD criteria with 4 patients fulfilling ≥5 criteria. BPD symptoms and depressive symptoms showed a strong correlation, and BPD symptoms were additionally correlated with emotional abuse and rejection sensitivity. There was no association between BPD features at baseline and improvement on the MADRS, however, BPD features tended to be associated with a lower response according to the BDI-II score after 10 weeks of treatment. Furthermore, BPD symptoms (i.e., abandonment, impulsivity and affective instability) were reduced after 10 weeks of CBASP treatment. Discussion: BPD symptoms are prevalent in patients with PDD and highly intertwined with the experience of depressive symptoms. In this naturalistic study in PDD, BPD features at baseline did not limit the clinical response to CBASP. Future studies may extend the spectrum of PDD to comorbid subsyndromal or even syndromal BPD in order to develop tailored psychotherapeutic treatment for these complex affective disorders.

Effects of alliance ruptures and repairs on outcomes

This study explored whether treatment outcomes in a trial on the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) vs. Supportive Psychotherapy (SP) for patients with early-onset chronic depression differ between alliance patterns.

Session-to-session ratings of the therapeutic alliance (Helping Alliance Questionnaire (HAQ)) from 254 outpatients with chronic depression (CBASP: 134; SP: 120) who took part in a multicenter randomized controlled trial of CBASP vs. SP were used to categorize patients into three alliance pattern categories for the patients' and therapists' rating separately. Based on the reliable change in the HAQ from one session to the next categories were: no rupture, unrepaired rupture, rupture-repair. Depression severity (24-item Hamilton Rating Scale for Depression) at post-treatment, at 12- and 24- months follow-up was the outcome.

The alliance pattern categories for therapists and patients did not differ between CBASP and SP. Only the alliance patterns calculated for patients were associated with outcome: in the unrepaired rupture category, patients had higher HRSD-ratings across time points (p = 0.047).

CBASP was not associated with more or fewer ruptures or repairs as compared to SP in the treatment of chronic depression. The study highlights the need to resolve ruptures to avoid poor outcomes.Trial registration: ClinicalTrials.gov identifier: NCT00970437.

Interpersonal Change During Inpatient CBASP Treatment: Focus on Group Therapy

Background: The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has been tailored specifically to the demands of patients with persistent depressive disorder (PDD). According to the CBASP model, PDD patients are supposed to live perceptually disconnected from their social environment, which consequently maintains depression. While initially developed as an individual treatment modality, the adaptation for group therapy yields an important interpersonal space. However, little is known about the specific factors that contribute to patients' benefit from the CBASP group modality. Methods: The analyzed sample comprised N = 87 PDD patients who completed a 12 week multimodal inpatient treatment including 2 weekly CBASP-specific individual and group sessions, respectively, as well as CBASP-unspecific medical contacts, pharmacotherapy and complementary therapies. Group sessions included trainings in situational analysis and interpersonal skills. Interpersonal change over therapy was examined based on the patients' self-perceived interpersonal problems (IIP) and the impact messages as perceived by their individual therapists (IMI). Pre and post-treatment data were compared using within-sample t-tests. Additionally, patients evaluated CBASP group therapy on a feedback form. They were invited to reflect on individual benefits and its helpful and unhelpful aspects. Qualitative content analysis with inductive category development was used to analyze feedback. Inter-rater reliability was computed to confirm categories before summarizing the frequencies of reported factors. Results: Self-perceived interpersonal distress significantly decreased over therapy. Patients reported reduced interpersonal problems and therapists reported more friendly and dominant impact messages. Interestingly, patients who showed a significant depressive symptom reduction described higher change scores. Regarding qualitative data, patients reported five main benefits from group therapy: Gain in social competence, self-confidence, self-reflection, interpersonal dynamics, and optimism/universality. Patients responding to CBASP identified significantly more factors than non-responders. Conclusions: Compared to studies with individual CBASP only, the present findings suggest that CBASP group therapy may contribute to the improvement of interpersonal behavior. Group therapy is discussed as a potential boosting effect for individual CBASP. However, as the present data were collected in a multimodal inpatient setting without competitor, randomized controlled trials are warranted that investigate the specific benefits of the group modality or the combined individual and group therapy over individual CBASP only.

Reduced Social Connectedness and Compassion Toward Close Others in Patients With Chronic Depression Compared to a Non-clinical Sample

Reduced social functioning in depression has been explained by different factors. Reduced social connectedness and prosocial motivation may contribute to interpersonal difficulties, particularly in chronic depression. In the present study, we tested whether social connectedness and prosocial motivation are reduced in chronic depression. Forty-seven patients with persistent depression and 49 healthy controls matched for age and gender completed the Inclusion of the Other in the Self Scale (IOS), the Compassionate Love Scale (CLS), the Beck Depression Inventory-II, and the Childhood Trauma Questionnaire. A Multivariate analysis of variance (MANOVA) with IOS and CLS as dependent variables revealed a highly significant difference between both groups. The IOS and the CLS-subscale Close Others were lower in persistent depression, whereas there was no difference in the CLS-subscale Strangers/Humanity. IOS and CLS-Close Others showed significant negative correlations with depressive symptoms. Connectedness to family members as measured by the IOS was negatively correlated with childhood trauma in patients with chronic depression. The results indicate that compassion and perceived social connection are reduced in depressed patients toward close others, but not to others in general. Implications for the treatment of depression are discussed.

Loneliness, Social Isolation and Their Difference: A Cross-Diagnostic Study in Persistent Depressive Disorder and Borderline Personality Disorder

Background: Interpersonal difficulties are a key feature of persistent depressive disorder (PDD) and borderline personality disorder (BPD). Caught in a vicious circle of dysfunctional interpersonal transaction, PDD and BPD patients are at great risk of experiencing prolonged loneliness. Loneliness, in turn, has been associated with the development of mental disorders and chronic illness trajectories. Besides, several factors may contribute to the experience of loneliness across the lifespan, such as social network characteristics, a history of childhood maltreatment (CM), and cognitive-affective biases such as rejection sensitivity (RS). This cross-diagnostic study approached the topic of perceived loneliness by comparing PDD and BPD patients with healthy controls (HC) in its interplay with symptom burden, social network characteristics, RS as well as CM. Method: Thirty-four PDD patients (DSM-5; 15 female, Mage = 38.2, SD = 12.3), 36 BPD patients (DSM-5; 19 female, Mage = 28.8, SD = 9.2), and 70 age- and gender-matched HC were assessed cross-sectionally using the following self-report measures: UCLA Loneliness Scale, Social Network Index (SNI; size, diversity, and embeddedness), Beck Depression Inventory (BDI-II), Borderline Symptom List (BSL-23), Childhood Trauma Questionnaire (CTQ), and Rejection Sensitivity Questionnaire (RSQ). Results: Both patient groups reported significantly higher levels of perceived loneliness, symptom severity, and smaller social network characteristics compared to HC. Loneliness was significantly correlated with severity of self-reported clinical symptoms in PDD and at trend level in BPD. Besides, loneliness tended to be related to social network characteristics for all groups except PDD patients. Both PDD and BPD patients showed higher RS as well as CTQ scores than HC. A history of emotional abuse and emotional neglect was associated with loneliness, and this association was mediated by RS as demonstrated by an exploratory mediation analysis. Discussion: Loneliness is highly prevalent in PDD and BPD patients and contributes to the overall symptom burden. Interestingly, loneliness showed an association with prior experiences of CM as well as current RS. We therefore propose a comprehensive model on how intra- und interpersonal aspects may interplay in the dynamics of loneliness in light of CM. Finally, this model may have further implications for psychotherapeutic interventions.

Understanding versus feeling the emotions of others: How persistent and recurrent depression affect empathy

Empathy refers to the ability to understand the emotions of others. It encompasses a cognitive component of decoding a mental state, and an affective component that relates to an emotional response. Deficits in empathy have been associated with social dysfunction in depression. It is further assumed that impairments are aggravated when depression takes a chronic course. Existing evidence in the literature, however, is scarce and heterogeneous. The present study investigated empathy in patients with persistent and recurrent depression as well as in healthy controls (N = 102). Empathy measurements included both self-report (Interpersonal Reactivity Index, IRI) as well as a laboratory task (Multifaceted Empathy Task, MET). A mixed model analyses of covariance, which accounted for differences in executive functioning, found no evidence for impaired cognitive empathy in depression. All three groups performed equally well in understanding mental states. However, both IRI and MET confirmed the hypothesis of significant deficits in affective empathy. Patients reported higher personal distress than controls, and showed lower affective responses towards positive emotions in others. There was no difference between patient groups. Childhood maltreatment was further related to reduced affective empathy. The present results contribute to our understanding of social dysfunction in depression, since loss of emotional reactivity to the feelings of others is considered to reduce the desire to engage in social interaction, thus leading to isolation and aggravation of depression.

Group Cognitive Behavioural Analysis System of Psychotherapy (CBASP) for persistently depressed outpatients: a retrospective chart review

BACKGROUND

Cognitive behavioural analysis system of psychotherapy (CBASP) is an effective individual treatment for persistent depressive disorder (PDD), but evidence on group treatment (Group-CBASP) is limited. Our aim was to review the effect of Group-CBASP on self-report depression severity in outpatients with PDD, overall and by age of depression-onset.

METHODS

A retrospective chart review study (November 2011-March 2017) in 54 patients with PDD (29 late-onset, 25 early-onset). Patients were previously treated by pharmacotherapy (92.6%), psychotherapy (98.1%) and/or electroconvulsive therapy (11.1%). Group-CBASP involved 24 weekly sessions during 6 months, followed by individual appointments over 6 months. The Inventory of Depressive Symptoms -self rating(IDS-SR) was used at baseline and after 3, 6, 9 and 12 months, computing mean differences and response rates.

RESULTS

The mean IDS-SR score decreased significantly from 39.83 at baseline to 33.78 at 6 months: a decrease from severe to moderate depression after 24 weeks of Group-CBASP, with a medium effect size (Cohen's d = .49). At 12 months, the mean IDS-SR score was 32.81, indicating moderate symptom levels remained. At 6 and 12 months, mean IDS-SR scores were similar among late- versus early-onset patients, but at 12 months response rates were higher among late-onset patients.

LIMITATIONS

Although results of our study provide valuable input for future prospective studies, limitations were the use of a retrospective design and the small group size.

CONCLUSION

Group-CBASP offered to an outpatient population with PDD was associated with clinically relevant decrease in self-reported symptom severity, and with sustained response particularly in patients with late onset of depression.

PRACTITIONER POINTS

Group-CBASP seems to be a good alternative for CBASP in individual setting. Patients with late age of depression-onset seem to benefit more from Group-CBASP. This study shows that clinical relevant effects of Group-CBASP, followed by individual contacts, remain at least for 6 months. Research on personalizing treatment strategies is needed to improve patient assignment for Group-CBASP.

A comparison of the three year course between chronic depression and depression with multiple vs. few prior episodes

This study tested the hypothesis that chronic depression (CD) is more similar to depression with multiple prior episodes (ME) than to depression with few prior episodes (FE). Data from participants (n = 1013) with mild to moderate depressive symptoms (Patient Health Questionnaire [PHQ-9] score 5 - 14) who took part in a randomized control trial of an internet intervention for depression (EVIDENT trial) were re-analyzed. The MINI-interview was conducted to diagnose CD (n = 376). If CD was not diagnosed, the self-reported number of depressive episodes was used to categorize participants as having episodic depression with up to five (FE, n = 422) or more than five (ME, n = 215) prior episodes. Over a three-year period, participants were assessed repeatedly regarding the course of depression (PHQ-9, QIDS), quality of life (SF-12) and therapeutic progress (FEP-2). At baseline, most scores were different between CD and FE but comparable between CD and ME. Time to remission did not differ between CD and ME but was longer in CD compared to FE. Results suggest that ME closely resembles CD and that CD differs from FE.

Preoperational Thinking as a Measure of Social Cognition Is Associated With Long-Term Course of Depressive Symptoms. A Longitudinal Study Involving Patients With Depression and Healthy Controls

BACKGROUND

Deficits in social cognition, referred to as preoperational thinking, are assumed to play a key role in the pathogenesis of persistent depression. The aim of this study was to explore the effect of preoperational thinking on the two-year course of depressive symptoms in a sample of persistently depressed, episodically depressed as well as healthy participants.

METHODS

We recruited 43 persistently depressed participants, 26 episodically depressed participants and 16 healthy control participants. Preoperational thinking was assessed at baseline with the Luebeck Questionnaire for Recording Preoperational Thinking. Over the period of two years, the course of depressive symptom severity was measured every three months using the Inventory of Depressive Symptomatology.

RESULTS

Using linear mixed model analysis we found a significant effect for the influence of preoperational thinking on the severity of depressive symptoms in the observation period. We found a non-significant statistical trend for an association of preoperational thinking with the change of depressive symptom severity.

CONCLUSION

Our analyses suggest that a high degree of preoperational thinking is associated with a higher severity of depressive symptoms and possibly less symptom improvement. These findings support the notion that preoperational thinking is a relevant factor for the further course of depression and might indeed contribute to the maintenance of persistent depression.

Patients' interpersonal problems as moderators of depression outcomes in a randomized controlled trial comparing mindfulness-based cognitive therapy and a group version of the cognitive-behavioral analysis system of psychotherapy in chronic depression

OBJECTIVES

Interpersonal problems were examined as moderators of depression outcomes between mindfulness-based cognitive therapy (MBCT) and cognitive behavioral analysis system of psychotherapy (CBASP) in patients with chronic depression.

METHODS

Patients received treatment-as-usual and, in addition, were randomized to 8-weeks of MBCT (n = 34) or 8-weeks of CBASP (n = 34). MBCT and CBASP were given in a group format. The Hamilton depression rating scale (HAM-D) was the primary and the Beck Depression Inventory (BDI-II) the secondary outcome. The subscales of the Inventory of interpersonal problems (IIP-32) were moderators. Multilevel models were performed.

RESULTS

Higher scores on the "vindictive/self-centered" subscale were associated with a better outcome in MBCT than in CBASP (HAM-D: p < .01; BDI-II: p < .01). Higher scores on the "nonassertive" subscale were associated with a better outcome in CBASP than in MBCT (HAM-D: p < .01; BDI-II: p < .01).

CONCLUSIONS

If these results can be replicated in larger trials, MBCT should be preferred to CBASP in chronically depressed patients being vindictive/self-centered, whereas CBASP should be preferred to MBCT in chronically depressed patients being nonassertive.

Suicide attempts in chronically depressed individuals: What are the risk factors?

Chronically depressed individuals have a high suicide risk. However, it is an open question whether previously observed risk factors for suicide attempts also apply to chronic depression or whether there are specific risk factors related to chronic-recurrent illness. We drew from a large group of chronically depressed individuals seeking psychotherapy to investigate demographic and psychological factors related to previous suicide attempts. Participants took part in the SCID and filled out established questionnaires. Among 368 chronically depressed individuals (68.7% women; M_age = 40.95 years), 75 participants (19.4%) reported previous suicide attempts. Men were more likely to have used violent methods. We tested the links of having attempted suicide with different variables using logistic regression analyses. Our findings corroborate previously observed risk factors (e.g. sexual abuse, personality disorders) and suggest other risk factors which could be especially relevant in chronic depression (e.g. depression severity, interpersonal problems, self-injurious behavior, and overall years of depression). Other risk factors from previous studies were not related to suicidal behavior within our sample (e.g. anxiety disorders, PTSD). Thus, mental health professionals should be aware that risk factors for suicidal behavior might vary between diagnosis groups and that chronic illness might be a risk factor in itself.

Predicting individual clinical trajectories of depression with generative embedding

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Patients with major depressive disorder (MDD) show variable clinical trajectories.

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Generative embedding (GE) is used to predict clinical trajectories in MDD patients.

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GE classifies patients with chronic depression vs. fast remission with 79% accuracy.

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GE provides mechanistic interpretability and outperforms conventional measures.

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Proof-of-concept that illustrates the potential of GE for clinical prediction.

Patients with major depressive disorder (MDD) show heterogeneous treatment response and highly variable clinical trajectories: while some patients experience swift recovery, others show relapsing-remitting or chronic courses. Predicting individual clinical trajectories at an early stage is a key challenge for psychiatry and might facilitate individually tailored interventions. So far, however, reliable predictors at the single-patient level are absent. Here, we evaluated the utility of a machine learning strategy – generative embedding (GE) – which combines interpretable generative models with discriminative classifiers. Specifically, we used functional magnetic resonance imaging (fMRI) data of emotional face perception in 85 MDD patients from the NEtherlands Study of Depression and Anxiety (NESDA) who had been followed up over two years and classified into three subgroups with distinct clinical trajectories. Combining a generative model of effective (directed) connectivity with support vector machines (SVMs), we could predict whether a given patient would experience chronic depression vs. fast remission with a balanced accuracy of 79%. Gradual improvement vs. fast remission could still be predicted above-chance, but less convincingly, with a balanced accuracy of 61%. Generative embedding outperformed classification based on conventional (descriptive) features, such as functional connectivity or local activation estimates, which were obtained from the same data and did not allow for above-chance classification accuracy. Furthermore, predictive performance of GE could be assigned to a specific network property: the trial-by-trial modulation of connections by emotional content. Given the limited sample size of our study, the present results are preliminary but may serve as proof-of-concept, illustrating the potential of GE for obtaining clinical predictions that are interpretable in terms of network mechanisms. Our findings suggest that abnormal dynamic changes of connections involved in emotional face processing might be associated with higher risk of developing a less favorable clinical course.

Persistent depressive disorder across the adult lifespan: results from clinical and population-based surveys in Germany

BACKGROUND

Although the individual and economic disease burden of depression is particularly high for long-term symptoms, little is known of the lifetime course of chronic depression. Most evidence derives from clinical samples, and the diagnostic distinction between persistent depressive disorder (PDD) and non-chronic major depression (NCMDD) is still debated. Thus, we examined characteristics of PDD among clinical vs. non-clinical cases, and the associated disease burden at a population level.

METHODS

Data were drawn from the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH, 2009-2012, n = 4483) and a clinical sample of PDD inpatients at Charité - Universitätsmedizin Berlin (2018-2019, n = 45). The DSM-5 definition of PDD was operationalized a priori to the study using interview-based DSM-IV diagnoses of dysthymia and major depression lasting at least 2 years in both surveys. Additional depression characteristics (depression onset, self-classified course, suicidality, comorbid mental disorders, treatment history and current depressive symptoms [Patient Health Questionnaire-9]) were assessed. In the DEGS1-MH, health-related quality of life (Short Form Health Survey-36, SF-36), chronic somatic conditions, number of sick days (past 12 months) or days with limitations in normal daily life activities (past 4 weeks), and health service utilization (past 12 months) were compared for PDD vs. NCMDD.

RESULTS

PDD cases from the clinical sample had a significantly earlier depression onset, a higher proportion of self-classification as persistent course, and treatment resistance than PDD and NCMDD cases in DEGS1-MH. At a population level, PDD cases showed worse outcomes compared with NCMDD cases in terms of somatic comorbidity, SF-36 mental component score, and activity limitations owing to mental health problems, as well as a higher risk for outpatient mental health care contact.

CONCLUSIONS

The distinction between PDD and NCMDD proposed for DSM-5 seems warranted. Early onset depression, self-classification as persistent depressive course, and treatment resistance are suggested as markers of more severe and chronic depression courses. At a population level, PDD is associated with remarkably higher individual and economic disease burden than NCMDD, highlighting the need to improve medical recognition of chronic courses and establish specific treatment concepts for chronic depression.

Social Cognition and Interpersonal Problems in Persistent Depressive Disorder vs. Episodic Depression: The Role of Childhood Maltreatment

Objective: Little is known about the specific psychological features that differentiate persistent depressive disorder (PDD) and episodic depression (ED). Thus, the present study aimed to investigate differences in social cognition and interpersonal problems between these two forms of depression and healthy controls. In addition, we aimed to examine childhood maltreatment (CM) as a possible origin of these alterations. Methods: In a cross-sectional study, adult patients with a current PDD (n = 34) or in a current episode of ED (n = 38), and healthy controls (n = 39) completed questionnaires about depression severity, empathy, interpersonal problems, and CM, as well as tests of affective theory of mind and facial emotion recognition. Results: Patients with PDD reported higher empathic distress than patients with ED and healthy controls. Both depressive groups recognized angry faces with higher accuracy and reported more interpersonal problems, with no differences between PDD and ED. Empathic distress and interpersonal problems mediated the link between CM and depression in the combined sample. Limitations: Patient groups were not drug-naïve and antidepressant intake might have influenced social-cognitive functions. Self-report measures of empathy and interpersonal problems are vulnerable to bias. The cross-sectional design does not allow causal conclusions. Conclusion: Depressed patients may not show deficits in decoding the affective states of others and in feeling with others. However, depressed individuals-in particular patients with PDD-may feel easily overwhelmed by emotionally tense situations, resulting in empathic distress and avoidant/submissive interpersonal behavior. Exposure to CM might be an origin of alterations in social cognition and interpersonal problems.

Response to ostracism in patients with chronic depression, episodic depression and borderline personality disorder a study using Cyberball

BACKGROUND

Social exclusion (ostracism) can lead to interactional frustration and may play an important role as trigger and symptom amplifier in affective disorders. To investigate immediate emotional and behavioral reactions as well as coping, social exclusion can be mimicked in experimental situations, e.g. in the Cyberball paradigm, a virtual ball tossing game which is well established in social psychology. The present cross-diagnostic study compares the responses to social exclusion in patients with chronic depression (CD), episodic depression (ED) and borderline personality disorder (BPD) in comparison to a healthy control group.

METHODS

After baseline characterization, 120 participants (29 patients with CD, 20 with ED, 28 with BPD and 43 healthy controls) played Cyberball with two virtual players and complete exclusion after three times receiving the ball. Thereafter, standard questionnaires were applied for measuring needs, threats, inner tension, emotions and behavioral intentions.

RESULTS

Patients with CD showed a higher intensity of ostracism and aversive impact, as well as the wish to escape the situation (behavioral intention) compared to ED. In most categories, CD and ED had scores between BPD and healthy controls (with this sequence) and with BPD patients showing the largest difference to healthy controls.

LIMITATIONS

The assessment did neither include objective behavioral measures (which is a general limitation in the majority of studies using Cyberball) nor any biological variables. The sample sizes of the diagnostic subgroups were moderate.

CONCLUSIONS

These findings support the hypothesis that social exclusion situations lead to a more aversive emotional and behavioral reaction in CD compared to ED. Psychological and biological underpinnings of these reactions should be addressed in future transdiagnostic studies. Moreover, psychotherapy in CD should focus on specific needs of CD patients for developing a functional coping in threatening interpersonal situations.

Prevalence of depression in patients with cancer in Iran: a systematic review and meta-analysis

Introduction

It is generally accepted that depression, affecting the quality of life, is a serious and common complication in patients with cancer. Given that there is no integrated study on this topic in Iran, the present study sought to investigate the prevalence of depression in patients with cancer by a systematic review and meta-analysis.

Methods

To meet the study objectives, all English and Persian papers published from 2000 to January 2018 were systematically collected and the data were extracted for analysis.

Results

There were 14 studies which were selected on the basis of the inclusion and exclusion criteria. A total number of 2831 patients with cancer had participated in the studies. The prevalence of depression among Iranian patients with cancer was 35% (95% CI 16% to 70%) based on random effects model. Among various types of cancer, the highest prevalence of depression appeared to patients suffering from breast cancer.

Conclusion

The prevalence of depression among patients with cancer in Iran was higher than the developed countries. As depression affects the quality of life of patients with cancer, the results can help policymakers and service providers in planning to reduce the prevalence of depression.

Negative mood induction: Affective reactivity in recurrent, but not persistent depression

BACKGROUND

Despite the high clinical and epidemiological relevance of persistent depression, little is known about its specific psychopathology and whether it is distinct from recurrent depression. Depression in general has been associated with blunted affective reactivity but the evidence from previous studies is inconsistent. Here, we asked whether affective reactivity might differ between persistent and recurrent depression.

METHODS

Twenty patients with persistent depression, 20 patients with recurrent depression and 20 healthy controls (HC) were recruited. Both patient groups showed moderate symptom severity. All participants underwent a sad mood induction procedure. Affective reactivity was assessed with the Positive and Negative Affect Schedule (PANAS) before and after mood induction.

RESULTS

We found a striking difference in affective reactivity between patient groups. While the persistent group showed blunted reactivity to mood induction, the recurrent group demonstrated an affective response that was comparable to HC, with an increase in negative and a decrease in positive affect. Blunted affective reactivity was thus specifically associated with persistent in contrast to recurrent depression.

CONCLUSIONS

These results highlight affective reactivity as an important psychopathological feature that differs between the two patient groups. Preserved affective reactivity to emotional stimuli in the recurrent group might reflect a resilience factor against persistence of depression.