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Teo MTL. Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109644. [PMID: 38216330 DOI: 10.1136/jme-2023-109644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.
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Affiliation(s)
- Marcus T L Teo
- Centre for Biomedical Ethics, National University of Singapore, Singapore
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2
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Zu X, Xin J, Xie H, Xu X, Shen Y, Wang J, Tian S, Wen Y, Li H, Yang J, Fang Y. Characteristics of gut microbiota and metabolic phenotype in patients with major depressive disorder based on multi-omics analysis. J Affect Disord 2024; 344:563-576. [PMID: 37863362 DOI: 10.1016/j.jad.2023.10.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 09/13/2023] [Accepted: 10/15/2023] [Indexed: 10/22/2023]
Abstract
Depression is a chronic, relapsing mental illness, often accompanied by loss of appetite, increased fatigue, insomnia and poor concentration. Here, we performed serum and urine metabolomics and fecal 16S rDNA sequencing studies on 57 unmedicated patients with major depressive disorder (MDD) and 57 healthy controls to characterize the metabolic and flora profile of MDD patients. We observed significant differences in serum and urinary metabolome between MDD patients and healthy individuals. Specifically, glycerophospholipid metabolism, primary bile acid biosynthesis and linoleic acid metabolism were significantly disordered in serum, and aminoacyl-tRNA biosynthesis, arginine biosynthesis, purine metabolism, phenylalanine metabolism, alanine, aspartate and glutamate metabolism, and pyrimidine metabolism were significantly impaired in urine. On this basis, we identified four potential diagnostic biomarkers for carnitine and four fatty acid classes in serum and urine, respectively. In addition, we observed significant disturbances of the gut microbiota in MDD patients. Spearman correlation analysis showed that imbalances in the gut microbiota were associated with metabolic disturbances, suggesting an important role of the gut microbiota in the pathogenesis of MDD. Our study provides a theoretical basis for further understanding of the pathogenesis of depression and for future clinical diagnosis and screening, as well as a basis for targeting the gut flora to optimize its structure for the prevention and treatment of depression.
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Affiliation(s)
- Xianpeng Zu
- School of Pharmacy, Naval Medical University, Shanghai 200433, China
| | - Jiayun Xin
- School of Pharmacy, Naval Medical University, Shanghai 200433, China; School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Haisheng Xie
- School of Pharmacy, Naval Medical University, Shanghai 200433, China
| | - Xike Xu
- School of Pharmacy, Naval Medical University, Shanghai 200433, China
| | - Yunheng Shen
- School of Pharmacy, Naval Medical University, Shanghai 200433, China
| | - Jinxin Wang
- School of Pharmacy, Naval Medical University, Shanghai 200433, China
| | - Saisai Tian
- School of Pharmacy, Naval Medical University, Shanghai 200433, China
| | - Yukun Wen
- Department of Diving and Hyperbaric Medical Research, Naval Medical Center, Naval Medical University, Shanghai 200433, China
| | - Hongxia Li
- Department of Nutrition and Food Hygiene, Faculty of Naval Medicine, Naval Medical University, China.
| | - Jishun Yang
- Medical Security Center, Naval Medical Center, Naval Medical University, Shanghai 200433, China.
| | - Yiqun Fang
- Department of Diving and Hyperbaric Medical Research, Naval Medical Center, Naval Medical University, Shanghai 200433, China.
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3
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Vonk S, Lok A, Dijkstra E, van Oostrom I, Arns M, Scheepstra K. Effectiveness of rTMS in depression in young adults. Brain Stimul 2023; 16:645-646. [PMID: 36935002 DOI: 10.1016/j.brs.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Affiliation(s)
- Sanne Vonk
- Amsterdam UMC, Univ of Amsterdam, Adult Psychiatry, Amsterdam Neuroscience, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Anja Lok
- Amsterdam UMC, Univ of Amsterdam, Adult Psychiatry, Amsterdam Neuroscience, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Eva Dijkstra
- Neurowave, Amsterdam, the Netherlands; Research Institute Brainclinics, Brainclinics Foundation, Nijmegen, the Netherlands
| | | | - Martijn Arns
- Dept. of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands; Research Institute Brainclinics, Brainclinics Foundation, Nijmegen, the Netherlands
| | - Karel Scheepstra
- Amsterdam UMC, Univ of Amsterdam, Adult Psychiatry, Amsterdam Neuroscience, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Neuroimmunology Research Group, Netherlands Institute for Neuroscience, Meibergdreef 47, 1105, BA, Amsterdam, the Netherlands.
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van Dijk DA, Meijer RM, van den Boogaard TM, Spijker J, Ruhé HG, Peeters FPML. Worse off by waiting for treatment? The impact of waiting time on clinical course and treatment outcome for depression in routine care. J Affect Disord 2023; 322:205-211. [PMID: 36372129 DOI: 10.1016/j.jad.2022.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/31/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Long-term untreated major depressive disorder (MDD) is associated with a less favorable clinical course. Waiting time, defined as the interval between diagnostic workup and treatment initiation, may be clinically relevant given the prolongation of the pre-existing duration of untreated MDD. However, it is currently unknown whether and to what extent waiting time affects treatment course in routine outpatient care. METHODS Retrospectively extracted data from 715 outpatients with MDD who received naturalistic outpatient MDD treatment were examined. Treatment outcome was defined as the difference in depression severity at the start of treatment and six months thereafter. Clinical course during waiting time was defined by the difference in severity at diagnostic workup and at treatment initiation. We analyzed the association between waiting time and treatment outcome and between waiting time and clinical course during this waiting time using multivariable regression analyses. We adjusted for severity and suicidality as potential confounders. RESULTS An increased duration of the waiting time was associated with a less favorable treatment outcome (B = 0.049, SE = 0.019, p = 0.01). This association persisted after adjustment for potential confounders (B = 0.053, SE = 0.02, p = 0.01). No association was found between length of waiting time and clinical course during waiting time. LIMITATIONS Strict definitions resulted in smaller sample sizes for the final analyses. The uncontrolled design may be questionable to definitively establish the impact of waiting time on treatment outcome. CONCLUSIONS A prolonged waiting time is significantly associated with less favorable treatment outcome. Reduction of waiting time deserves priority in depression treatment planning to improve clinical outcomes.
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Affiliation(s)
- D A van Dijk
- Department of Clinical Psychological Science, Faculty of Psychology & Neuroscience, Maastricht University, Maastricht, the Netherlands; Parnassia Group, PsyQ Haaglanden, Department of Mood Disorders, The Hague, the Netherlands.
| | - R M Meijer
- Antes/Parnassia Psychiatric Institute, Rotterdam, the Netherlands
| | - Th M van den Boogaard
- Parnassia Group, PsyQ Haaglanden, Department of Mood Disorders, The Hague, the Netherlands
| | - J Spijker
- Pro Persona Mental Healthcare, Nijmegen, the Netherlands; Behavioural Science Institute, Radboud University, Nijmegen, the Netherlands
| | - H G Ruhé
- Department of Psychiatry, Radboudumc, Nijmegen, the Netherlands; Donders Institute for Brain and Behaviour, Radboud University, Nijmegen, the Netherlands
| | - F P M L Peeters
- Department of Clinical Psychological Science, Faculty of Psychology & Neuroscience, Maastricht University, Maastricht, the Netherlands
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van Dijk DA, Deen ML, van den Boogaard TM, Ruhé HG, Spijker J, Peeters FPML. Prevalence and prediction of dropout during depression treatment in routine outpatient care: an observational study. Eur Arch Psychiatry Clin Neurosci 2022:10.1007/s00406-022-01499-1. [PMID: 36253582 PMCID: PMC10359217 DOI: 10.1007/s00406-022-01499-1] [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: 01/31/2022] [Accepted: 09/27/2022] [Indexed: 11/24/2022]
Abstract
Efficacious treatments are available for major depressive disorder (MDD), but treatment dropout is common and decreases their effectiveness. However, knowledge about prevalence of treatment dropout and its risk factors in routine care is limited. The objective of this study was to determine the prevalence of and risk factors for dropout in a large outpatient sample. In this retrospective cohort analysis, routinely collected data from 2235 outpatients with MDD who had a diagnostic work-up between 2014 and 2016 were examined. Dropout was defined as treatment termination without achieving remission before the fourth session within six months after its start. Total and item scores on the Dutch Measure for Quantification of Treatment Resistance in Depression (DM-TRD) at baseline, and demographic variables were analyzed for their association with dropout using logistic regression and elastic net analyses. Data of 987 subjects who started routine outpatient depression treatment were included in the analyses of which 143 (14.5%) dropped out. Higher DM-TRD-scores were predictive for lower dropout odds [OR = 0.78, 95% CI = (0.70-0.86), p < 0.001]. The elastic net analysis revealed several clinical variables predictive for dropout. Higher SES, higher depression severity, comorbid personality pathology and a comorbid anxiety disorder were significantly associated with less dropout in the sample. In this observational study, treatment dropout was relatively low. The DM-TRD, an easy-to-use clinical instrument, revealed several variables associated with less dropout. When applied in daily practice and combined with demographical information, this instrument may help to reduce dropout and increase treatment effectiveness.
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Affiliation(s)
- D A van Dijk
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands. .,Department of Mood Disorders, PsyQ Haaglanden, The Hague, The Netherlands. .,Parnassia Psychiatric Institute, Monsterseweg 93, 2553 RJ, The Hague, The Netherlands.
| | - M L Deen
- Parnassia Psychiatric Institute, The Hague, The Netherlands.,Institute of Psychology, Leiden University, Leiden, The Netherlands
| | | | - H G Ruhé
- Department of Psychiatry, Radboudumc, Nijmegen, The Netherlands.,Donders Institute for Brain and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - J Spijker
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands.,Pro Persona Mental Healthcare, Nijmegen, The Netherlands
| | - F P M L Peeters
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
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Negative cognitive schema modification as mediator of symptom improvement after electroconvulsive therapy in major depressive disorder. J Affect Disord 2022; 310:156-161. [PMID: 35490877 DOI: 10.1016/j.jad.2022.04.088] [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: 08/12/2021] [Revised: 02/20/2022] [Accepted: 04/13/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a potent option for treatment-resistant major depressive disorder (MDD). Cognitive models of depression posit that negative cognitions and underlying all-or-nothing negative schemas contribute to and perpetuate depressed mood. This study investigates whether ECT can modify negative schemas, potentially via memory reactivation, and whether such changes are related to MDD symptom improvement. METHOD Seventy-two patients were randomized to either an emotional memory reactivation electroconvulsive therapy (EMR-ECT) or control memory reactivation electroconvulsive therapy (CMR-ECT) intervention prior to ECT-sessions in a randomized controlled trail. Emotional memories associated with patients' depression were reactivated before ECT-sessions. At baseline and after the ECT-course, negative schemas and depression severity were assessed using the Dysfunctional Attitude Scale (DAS) and Hamilton Depression Rating Scale HDRS. Mediation analyses were used to examine whether the effects of ECT on HDRS-scores were mediated by changes in DAS-scores or vice versa. RESULTS Post-ECT DAS-scores were significantly lower compared to baseline. Post-ECT, the mean HDRS-score of the whole sample (15.10 ± 8.65 [SD]; n = 59) was lower compared to baseline (24.83 ± 5.91 [SD]). Multiple regression analysis showed no significant influence of memory reactivation on schema improvement. Path analysis showed that depression improvement was mediated by improvement of negative cognitive schemas. CONCLUSION ECT is associated with improvement of negative schemas, which appears to mediate the improvement of depressive symptoms. An emotional memory intervention aimed to modify negative schemas showed no additional effect.
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Abstract
Staging has been increasingly used in unipolar depression since its introduction in the nineties. Several models are available, but their differential features and implications are not completely clear. We systematically reviewed: (a) staging models of longitudinal development of unipolar depression; (b) staging models of treatment-resistant unipolar depression; (c) their applications. MEDLINE, PsycINFO, EMBASE, and Web of Science were examined according to PRISMA guidelines from inception to December 2021. Search terms were: 'stage/staging', combined using the Boolean 'AND' operator with 'psychiatric disorder/mental disorder/depressive/mood disorder'. A total of 169 studies were identified for inclusion: 18 described staging models or applications, 151 described treatment-resistant staging models or applications. Staging models of longitudinal development were found to play a key role in formulating sequential treatment, with particular reference to the use of psychotherapy after pharmacotherapy. Staging methods based on treatment resistance played a crucial role in setting entry criteria for randomized clinical trials and neurobiological investigations. Staging is part of clinimetrics, the science of clinical measurements, and its role can be enhanced by its association with other clinimetric strategies, such as repeated assessments, organization of problematic areas, and evaluation of phenomena that may affect responsiveness. In research, it may allow to identify more homogeneous populations in terms of treatment history that may diminish the likelihood of spurious results in comparisons. In clinical practice, the use of staging in a clinimetric perspective allows clinicians to make full use of the information that is available for an individual patient at a specific time.
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Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy
- Clinical Pharmacopsychology Laboratory, University of Florence, Florence, Italy
- Department of Psychiatry & Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, New York, USA
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Muit JJ, van Eijndhoven PFP, Cipriani A, Dalhuisen I, van Bronswijk S, Furukawa TA, Ruhe HG. Efficacy and acceptability of next step treatment strategies in adults with treatment-resistant major depressive disorder: protocol for systematic review and network meta-analysis. BMJ Open 2022; 12:e056777. [PMID: 35437250 PMCID: PMC9016400 DOI: 10.1136/bmjopen-2021-056777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION For major depression, a one-size-fits-all treatment does not exist. Patients enter a 'trial-and-change' algorithm in which effective therapies are subsequently applied. Unfortunately, an empirically based order of treatments has not yet been determined. There is a magnitude of different treatment strategies while clinical trials only compare a small number of these. Network meta-analyses (NMA) might offer a solution, but so far have been limited in scope and did not account for possible differences in population characteristics that arise with increasing levels of treatment-resistance, potentially violating the transitivity assumption. We; therefore, present a protocol for a systematic review and NMA aiming at summarising and ranking treatments for treatment-resistant depression (TRD) while covering a broad range of therapeutic options and accounting for possible differences in population characteristics at increasing levels of treatment-resistance. METHODS AND ANALYSIS Randomised controlled trials will be included that compared next-step pharmacological, neuromodulation or psychological treatments for treatment-resistant depression (TRD; ie, failure to respond to ≥1 adequate antidepressant drug trial(s) in the current episode) to each other or to a control condition. Primary outcomes will be the proportion of patients who responded to (efficacy) and dropped out of (acceptability) the allocated treatment. A random effects NMA will be conducted, synthesising the evidence for each outcome and determining the differential efficacy of treatments. Heterogeneity in treatment nodes will be reduced by considering alternative geometries of the network structure and by conducting a meta-regression examining different levels of TRD. Local and global methods will be applied to evaluate consistency. The Cochrane Risk of Bias 2 tool, Confidence in Network Meta-Analysis and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework will be used to assess risk of bias and certainty. ETHICS AND DISSEMINATION This review does not require ethical approval.
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Affiliation(s)
- Jan Jacobus Muit
- Department of Psychiatry, Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Iris Dalhuisen
- Department of Psychiatry, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Suzanne van Bronswijk
- Department of Psychiatry and Psychology, Maastricht University, Maastricht, The Netherlands
| | - Toshi A Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, School of Public Health, Kyoto, Japan
| | - Henricus G Ruhe
- Department of Psychiatry, Radboud University Nijmegen, Nijmegen, The Netherlands
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van Bronswijk SC, van Dijk DA, van den Boogaard TM, Deen ML, Ruhé HG, Spijker J, Peeters FPML. Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care. Am J Psychother 2021; 74:150-156. [PMID: 34905935 DOI: 10.1176/appi.psychotherapy.202120200046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care. METHODS Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models. RESULTS Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders. CONCLUSIONS Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.
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Affiliation(s)
- Suzanne C van Bronswijk
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Dyllis A van Dijk
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Th Michael van den Boogaard
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Mathijs L Deen
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Henricus G Ruhé
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Jan Spijker
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Frenk P M L Peeters
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
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10
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van Bronswijk SC, van Dijk DA, van den Boogaard TM, Deen ML, Ruhé HG, Spijker J, Peeters FPML. Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care. Am J Psychother 2021:appipsychotherapy20200046. [PMID: 34134502 DOI: 10.1176/appi.psychotherapy.20200046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care. METHODS Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models. RESULTS Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders. CONCLUSIONS Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.
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Affiliation(s)
- Suzanne C van Bronswijk
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Dyllis A van Dijk
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Th Michael van den Boogaard
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Mathijs L Deen
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Henricus G Ruhé
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Jan Spijker
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
| | - Frenk P M L Peeters
- Department of Clinical Psychological Science, Maastricht University, Maastrich, the Netherlands (van Bronswijk, van Dijk, Peeters); Department of Psychiatry and Psychology, Maastricht University Medical Center+, Maastricht, the Netherlands (van Bronswijk); Department of Mood Disorders, PsyQ Haaglanden, the Hague, the Netherlands (van Dijk, van den Boogaard); Parnassia Psychiatric Institute, the Hague (Deen); Institute of Psychology, Leiden University, Leiden, the Netherlands (Deen); Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands (Ruhé); Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen (Ruhé); Pro Persona Mental Healthcare, and Behavourial Science Institute, Radboud University, Nijmegen (Spijker)
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Bokma WA, Batelaan NM, Penninx BW, van Balkom AJ. Evaluating a dimensional approach to treatment resistance in anxiety disorders: A two-year follow-up study. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021. [DOI: 10.1016/j.jadr.2021.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rybak YE, Lai KSP, Ramasubbu R, Vila‐Rodriguez F, Blumberger DM, Chan P, Delva N, Giacobbe P, Gosselin C, Kennedy SH, Iskandar H, McInerney S, Ravitz P, Sharma V, Zaretsky A, Burhan AM. Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment. Depress Anxiety 2021; 38:456-467. [PMID: 33528865 PMCID: PMC8049072 DOI: 10.1002/da.23135] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/14/2020] [Accepted: 12/23/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Treatment-resistant depression (TRD) is a debilitating chronic mental illness that confers increased morbidity and mortality, decreases the quality of life, impairs occupational, social, and offspring development, and translates into increased costs on the healthcare system. The goal of this study is to reach an agreement on the concept, definition, staging model, and assessment of TRD. METHODS This study involved a review of the literature and a modified Delphi process for consensus agreement. The Appraisal of Guidelines for Research & Evaluation II guidelines were followed for the literature appraisal. Literature was assessed for quality and strength of evidence using the grading, assessment, development, and evaluations system. Canadian national experts in depression were invited for the modified Delphi process based on their prior clinical and research expertize. Survey items were considered to have reached a consensus if 80% or more of the experts supported the statement. RESULTS Fourteen Canadian experts were recruited for three rounds of surveys to reach a consensus on a total of 27 items. Experts agreed that a dimensional definition for treatment resistance was a useful concept to describe the heterogeneity of this illness. The use of staging models and clinical scales was recommended in evaluating depression. Risk factors and comorbidities were identified as potential predictors for treatment resistance. CONCLUSIONS TRD is a meaningful concept both for clinical practice and research. An operational definition for TRD will allow for opportunities to improve the validity of predictors and therapeutic options for these patients.
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Affiliation(s)
- Yuri E. Rybak
- Department of PsychiatryWestern UniversityLondonOntarioCanada
| | - Ka S. P. Lai
- Department of PsychiatryWestern UniversityLondonOntarioCanada
| | | | - Fidel Vila‐Rodriguez
- Department of PsychiatryUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - Peter Chan
- Department of PsychiatryUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Nicholas Delva
- Department of PsychiatryQueen's UniversityKingstonOntarioCanada
| | - Peter Giacobbe
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Caroline Gosselin
- Department of PsychiatryUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - Hani Iskandar
- Department of PsychiatryMcGill UniversityMontrealQuebecCanada
| | - Shane McInerney
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Paula Ravitz
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Verinder Sharma
- Department of PsychiatryWestern UniversityLondonOntarioCanada
| | - Ari Zaretsky
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Amer M. Burhan
- Ontario Shores Centre for Mental Health SciencesWhitbyOntarioCanada,Department of PsychiatryUniversity of Toronto Temerty Faculty of MedicineTorontoOntarioCanada
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13
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Medeiros GC, Prueitt WL, Minhajuddin A, Patel SS, Czysz AH, Furman JL, Mason BL, Rush AJ, Jha MK, Trivedi MH. Childhood maltreatment and impact on clinical features of major depression in adults. Psychiatry Res 2020; 293:113412. [PMID: 32950785 DOI: 10.1016/j.psychres.2020.113412] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 08/03/2020] [Accepted: 08/17/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study examined: 1) the prevalence of childhood maltreatment (CMT) in individuals with chronic and/or recurrent depression, 2) the association between CMT and depressive symptoms, 3) the link between CMT and worse clinical presentation of depression, 4) the effects of accumulation of different types of CMT, and 5) the relationship between the age at CMT and depression. METHODS We analyzed the baseline data of 663 individuals from the CO-MED study. CMT was determined by a brief self-reported questionnaire assessing sexual abuse, emotional abuse, physical abuse, and neglect. Correlational analyses were conducted. RESULTS Half of the sample (n = 331) reported CMT. Those with CMT had higher rates of panic/phobic, cognitive and anhedonic symptoms than those without CMT. All individual types of maltreatment were associated with a poorer clinical presentation including: 1) earlier MDD onset; 2) more severe MDD, 3) more suiccidality, 4) worse quality of life, and functioning, and 5) more psychiatric comorbidities. Clinical presentation was worse in participants who reported multiple types of CMT. CONCLUSIONS In chronic and/or recurrent depression, CMT is common, usually of multiple types and is associated with a worse clinical presentation in MDD. The combination of multiple types of CMT is associated with more impairment.
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Affiliation(s)
- Gustavo C Medeiros
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William L Prueitt
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Abu Minhajuddin
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA
| | - Shirali S Patel
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA
| | - Andrew H Czysz
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA
| | - Jennifer L Furman
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA
| | - Brittany L Mason
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA
| | - A John Rush
- Duke-National University of Singapore, Singapore; Department of Psychiatry, Duke University Medical School, Durham, NC, USA; Department of Psychiatry, Texas Tech Health Science Center, Permian Basin, TX, USA
| | - Manish K Jha
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9070, USA.
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Li M, Niu J, Yan P, Yao L, He W, Wang M, Li H, Cao L, Li X, Shi X, Liu X, Yang K. The effectiveness and safety of acupuncture for depression: An overview of meta-analyses. Complement Ther Med 2019; 50:102202. [PMID: 32444032 DOI: 10.1016/j.ctim.2019.102202] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/19/2019] [Accepted: 09/28/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To provide an overview of existing meta-analysis (MAs) on the efficacy and safety of acupuncture for depression, and assess the methodological quality and the strength of evidence of the included MAs. METHODS We searched MAs of randomized trials that have evaluated the effects of acupuncture on depression in three international and three Chinese databases from their inception until August 2019. The methodological quality of included MAs was evaluated with the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), and the strength of evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). We used the intra-class correlation coefficient (ICC) to assess reviewer agreement in the pre-experiment. RESULTS We included 31 MAs and 59 RCTs. The results of included MAs were conflicting, our meta-analyses found that acupuncture may confer small benefit in reducing the severity of depression by end of treatment than no treatment/wait list/treatment as usual(SMD -0.74, 95% CI -1.06 to -0.41, eight trials, 624 participants), control acupuncture (invasive, non-invasive sham controls) (SMD 0.27, 95% CI -0.51 to -0.04, 20 trials, 1055 participants), antidepressants(Selective serotonin reuptake inhibitors (SSRI)/ Tetracyclic antidepressants(TCAs)) (SMD -0.28, 95% CI -0.46 to -0.10, 30 trials, 3068 participants), acupuncture plus antidepressants versus antidepressants(SSRI/TCAs) (SMD -0.99, 95% CI -1.37 to -0.61, 17 trials, 1110 participants). Subgroup analyses showed that there was no difference between electro-acupuncture and invasive control (P = 0.37), electro-acupuncture and non-invasive control (P = 0.90), manual acupuncture and Tetracyclic antidepressants (P = 0.57), electro-acupuncture and Tetracyclic antidepressants (P = 0.07). Six MAs concluded that acupuncture reduced the incidence of adverse events compared with antidepressants. The evaluation with AMSTAR-2 showed that the quality of included MAs was low or critically low. The results of the GRADE evaluation showed that the strength of evidence was low to very low for most outcomes. CONCLUSIONS Although acupuncture appears to be more effective and safer than no treatment, control acupuncture and antidepressants, the quality of the available evidence was very low. Further methodologically rigorous and adequately powered primary studies are needed to confirm the effectiveness of acupuncture for depression.
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Affiliation(s)
- Meixuan Li
- School of Public Health, Lanzhou University, Lanzhou, 730000, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, 730000, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Junqiang Niu
- The First Hospital of Lanzhou University, Lanzhou, 730000, China
| | - Peijing Yan
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Institute of Clinical Research and Evidence Based Medicine, The Gansu Provincial Hospital, Lanzhou, 730000, China
| | - Liang Yao
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, L8S4L8, Canada
| | - Wenbo He
- School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Meng Wang
- School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Huijuan Li
- School of Public Health, Lanzhou University, Lanzhou, 730000, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, 730000, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Liujiao Cao
- School of Public Health, Lanzhou University, Lanzhou, 730000, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, 730000, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Xiuxia Li
- School of Public Health, Lanzhou University, Lanzhou, 730000, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, 730000, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
| | - Xiue Shi
- Institute of Evidence Based Rehabilitation Medicine of Gansu Province, Lanzhou, 730000, China
| | - Xingrong Liu
- School of Public Health, Lanzhou University, Lanzhou, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, 730000, China.
| | - Kehu Yang
- School of Public Health, Lanzhou University, Lanzhou, 730000, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, 730000, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China; Institute of Clinical Research and Evidence Based Medicine, The Gansu Provincial Hospital, Lanzhou, 730000, China.
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