Fatigue in Patients with Major Depressive Disorder: Prevalence, Burden and Pharmacological Approaches to Management

Lower DTI-ALPS index in patients with major depressive disorder: Correlation with fatigue

BACKGROUND AND PURPOSE

Diffusion tensor imaging along perivascular spaces (DTI-ALPS) is an index that may provide insights into intracranial waste clearance processes. Glymphatic system dysfunction has been suggested to play a role in the development of major depressive disorder (MDD). Additionally, fatigue-a common precursor of MDD-is also closely connected to the waste clearance function of the central nervous system (CNS), further underscoring the significance of efficient waste removal in MDD. However, evidence linking altered DTI-ALPS index to MDD remains limited. This study aims to investigate the changes in the DTI-ALPS index in patients with MDD and explore the potential interplay between DTI-ALPS index alterations, fatigue, and the presence of MDD.

MATERIAL AND METHODS

A total of 46 patients with MDD and 55 healthy controls (HC) were included in the study. All participants underwent diffusion tensor imaging using the same 3-T MRI (3-Tesla Magnetic Resonance Imaging) scanner. The DTI-ALPS index was assessed, and the Chalder Fatigue Scale (CFS) was used to evaluate fatigue levels in both groups, and the 17-item Hamilton Depression Rating Scale (HAMD-17) was used to evaluate the severity of depression in the patients. We compared the DTI-ALPS index and clinical characteristics between the MDD and HC group, and explored the relationship among the DTI-ALPS index, CFS scores, and the presence of MDD through mediation analysis.

RESULTS

The DTI-ALPS index in the right hemisphere (DTI-ALPS-R) is significantly lower in patients with MDD (t = 2.41, P = 0.02). The MDD patients exhibited significantly higher scores on the CFS scales compared with HCs (t = 13.12, P <.001). Mediation analysis showed that the CFS score plays a significant mediating role between DTI-ALPS-R and the presence of MDD, acting as a full mediator (indirect effect β = -0.230, 95 % CI: [-0.388, -0.059]).

CONCLUSION

Our study found that patients with MDD have a reduced DTI-ALPS index. This reduction appears to contribute to the development of MDD by facilitating the accumulation of fatigue symptoms. These findings may provide a new perspective on the pathogenesis of MDD, suggest a potential new biomarker for MDD, and offer new insights for its treatment.

Bodily pain and vitality are the key factors in the disability of chronic low back pain patients under Short Form 36 base study: a five-year cohort study

BACKGROUND

Chronic low back pain (CLBP), a significant cause of disability, is expected to increase with aging. Short Form 36 (SF-36) indicated higher baseline component scores predict CLBP disability at shorter follow-ups, with unexplored five-year associations. The study aimed to test the associations of the physical and mental subscales of the SF-36 at baseline with disability at the five-year follow-up point among patients with CLBP.

METHODS

Patients aged between 20 and 65 years with CLBP were enrolled at baseline and followed at the five-year point. The Oswestry Disability Index (ODI), the physical functioning (PF) subscale of the SF-36, and self-reported total months of disability (TMOD) over the past five years were used as the indices of disability. The four physical and mental subscales of the SF-36 were used as independent factors, respectively. Multiple linear regression was used to compare the associations of the physical and mental subscales at baseline with disability at follow-up.

RESULTS

Two hundred twenty-five patients with CLBP were enrolled at baseline and 111 participated in followed at the five-year point. Among the SF-36 subscales, the scores of bodily pain (BP), vitality (VT), and social functioning (SocF) at baseline were significantly correlated with the three indices of disability at follow-up. After controlling for demographic and clinical variables, BP and VT at baseline were most strongly associated with the ODI and TMOD at follow-up among the four physical and mental subscales, respectively. PF at baseline was most strongly associated with itself at follow-up among the four physical subscales.

CONCLUSION

Our results demonstrated that both the physical and mental subscales of the SF-36 at baseline could predict disability at the five-year follow-up point among patients with CLBP. The BP and VT subscales were independent factors associated with disability among the physical and mental subscales, respectively.

Experiences of adult patients living with depression-related insomnia: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify and synthesize the best available evidence on how adult patients experience living with depression-related insomnia, and their experiences related to pharmacological and non-pharmacological interventions aimed at improving sleep.

INTRODUCTION

Insomnia affects 80% to 90% of patients with depression. The costs of insomnia are considerable for the individual and society alike. To understand the role and consequences of insomnia for an individual with depression and to optimize sleep interventions, an in-depth understanding of patients' experiences is needed. Therefore, this review addresses how adult patients experience living with depression-related insomnia, along with the experiences of pharmacological and non-pharmacological sleep interventions among patients with depression-related insomnia.

INCLUSION CRITERIA

Studies focusing on adult patients aged 18 years and older with a diagnosis of depression who had experiences with insomnia and pharmacological and/or non-pharmacological sleep interventions were included. All studies with qualitative research findings from inpatient and outpatient populations were considered.

METHODS

The following databases were searched: MEDLINE (PubMed), Embase (Elsevier), CINAHL (EBSCOhost), PsycINFO (ProQuest), Cochrane CENTRAL, SveMed+, Scopus, and Web of Science Core Collection. Google Scholar and ProQuest Dissertations and Theses were searched for eligible dissertations and theses. The searches were conducted on May 3-5, 2022, and updated on June 13-19, 2023. Studies published in English, Danish, German, Norwegian, and Swedish were considered. Databases were searched from their inception to the search date. All studies were screened against the inclusion criteria and critically and independently appraised by 2 reviewers for methodological quality. Findings were pooled using meta-aggregation, and a ConQual Summary of Findings was created.

RESULTS

Ten qualitative studies were included. The studies were conducted in 6 countries and counted a total of 176 participants. In all, 127 findings were extracted and aggregated into 11 categories. From the 11 categories, 3 synthesized findings were developed: 1) Disruption of sleep challenges coping with everyday life by depleting both physical and mental resources; 2) Sleep is an escape and a protective factor against suicide; and 3) Choices, support, and personalized interventions from non-pharmacological approaches addressing depression-related insomnia are valued.

CONCLUSIONS

This review underlined the relationship between depression-related insomnia, its profound impact on individuals' lives, and the value of non-pharmacological sleep interventions to address these issues. Specifically, the study revealed the physical and emotional consequences of insomnia while emphasizing how wakefulness during night hours may exacerbate feelings of loneliness and vulnerability to negative thoughts and suicide. Moreover, it provides an overview of patients' experiences of non-pharmacological approaches to address depression-related insomnia and highlights their diverse treatment experiences and preferences.

SUPPLEMENTAL DIGITAL CONTENT

A Danish-language version of the abstract of this review is available as Supplemental Digital Content [http://links.lww.com/SRX/A64].

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021276048.

High-density lipoprotein cholesterol abnormalities correlate with severe fatigue in major depressive disorder: A cross-sectional study

OBJECTIVES

This cross-sectional study aimed to characterize the differences of metabolic profiles and atherogenicity between various levels of fatigue severity in patients with major depressive disorder (MDD), and examine the extent to which metabolic abnormality correlates with fatigue severity.

METHODS

We recruited 119 patients with MDD and assessed fatigue severity using Krupp's Fatigue Severity Scale. Blood samples were collected to determine plasma levels of fasting glucose, high-density lipoprotein cholesterol (HDL-C), triglycerides, total cholesterol and low-density lipoprotein cholesterol. The atherogenic index of plasma (AIP) was calculated as log10 (triglycerides/HDL-C).

RESULTS

MDD with severe fatigue were more likely to be younger (43.3 ± 10.3 years vs. 49.4 ± 8.5 years, p = 0.001), had a younger age of onset (34.7 ± 9.7 years vs. 40.7 ± 9.5 years, p = 0.001), demonstrated higher HAMD scores (18.0 ± 7.6 vs. 10.9 ± 7.5, p < 0.001), as well as lower HDL-C levels (48.5 ± 10.8 vs. 55.3 ± 13.9, p = 0.003), a greater prevalence of low HDL-C (43.9% vs. 22.6%, p = 0.015) and higher AIP levels (0.4 ± 0.3 vs. 0.3 ± 0.3, p = 0.046). Both a decreased plasma HDL-C level (OR = 0.95, 95% CI = 0.91-0.99, p = 0.009) and a diagnosis of low HDL-C (OR = 3.29, 95% CI = 1.27-8.57, p = 0.015) were significantly correlated with an increased risk of fatigue severity.

CONCLUSION

HDL-C could potentially protect patients with MDD from severe fatigue and the associated risk of cardiovascular disease.

Association between fatigue and depressive symptoms in persons with post-COVID-19 condition: a post hoc analysis

OBJECTIVE

Post-COVID-19 Condition (PCC) is a prevalent, persistent and debilitating phenomenon occurring three or more months after resolution of acute COVID-19 infection. Fatigue and depressive symptoms are commonly reported in PCC. We aimed to further characterize PCC by assessing the relationship between fatigue and depressive symptom severity in adults with PCC.

METHODS

A post hoc analysis was conducted on data retrieved from a randomized, double-blinded, placebo-controlled study evaluating vortioxetine for cognitive deficits in persons with PCC. We sought to determine the relationship between baseline fatigue [i.e. Fatigue Severity Scale (FSS) total score] and baseline depressive symptom severity [i.e. 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR-16) total score] in adults with PCC.

RESULTS

The statistical analysis included baseline data from 142 participants. After adjusting for age, sex, education, employment status, history of major depressive disorder (MDD) diagnosis, self-reported physical activity, history of documented acute SARS-CoV-2 infection and body mass index (BMI), baseline FSS was significantly correlated with baseline QIDS-SR-16 (β = 0.825, p = .001).

CONCLUSION

In our sample, baseline measures of fatigue and depressive symptoms are correlated in persons living with PCC. Individuals presenting with PCC and fatigue should be screened for the presence and severity of depressive symptoms. Guideline-concordant care should be prescribed for individuals experiencing clinically significant depressive symptoms. Fatigue and depressive symptom severity scores were not pre-specified as primary objectives of the study. Multiple confounding factors (i.e. disturbance in sleep, anthropometrics and cognitive impairment) were not collected nor adjusted for in the analysis herein.

TRIAL REGISTRATION

Unrestricted Research Grant from H. Lundbeck A/S, Copenhagen, Denmark. ClinicalTrials.gov Identifier: NCT05047952.

Predicting the Persistence of Insomnia Symptoms during the COVID-19 Pandemic

OBJECTIVE

The goal of this study is to evaluate the factors associated with vulnerability and course of insomnia longitudinally in the COVID-19 pandemic and examine differences between: (a) those who never demonstrated clinical insomnia symptoms, (b) those who demonstrated clinically elevated insomnia symptoms at 1 or 2 time points, and (c) those who demonstrated clinically elevated insomnia symptoms at all 3 time points.

METHODS

Participants (≥18 years old) completed measures of insomnia (ISI), depression (PHQ-8), anxiety (GAD-7), and pre-sleep arousal (PSAS) at 3 time points (baseline, 1 month, and 3 months). Data were analyzed using univariable odds ratios and multivariable multicategory logistic regression to determine demographic, psychological, and behavioral predictors of insomnia persistence.

RESULTS

A total of 129 participants completed all 3 assessments (70 female, age M = 44 years, SD = 16). We found that 40% (N = 51) never had insomnia symptoms, 33% (N = 42) reported transient insomnia symptoms (1 or 2 time points), and 28% (N = 36) reported persistent insomnia symptoms (all 3 time points). From the multivariable multicategory logistic analyses, pre-sleep arousal, gender, and income were significant predictors of insomnia persistence.

CONCLUSIONS

Findings indicate elevated insomnia symptoms were persistent in a substantial number of individuals throughout the pandemic. Results suggest additional insomnia and psychological interventions are needed to improve sleep and mental health.

Systematic review of fatigue severity in ME/CFS patients: insights from randomized controlled trials

BACKGROUND

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a debilitating illness medically unexplained, affecting approximately 1% of the global population. Due to the subjective complaint, assessing the exact severity of fatigue is a clinical challenge, thus, this study aimed to produce comprehensive features of fatigue severity in ME/CFS patients.

METHODS

We systematically extracted the data for fatigue levels of participants in randomized controlled trials (RCTs) targeting ME/CFS from PubMed, Cochrane Library, Web of Science, and CINAHL throughout January 31, 2024. We normalized each different measurement to a maximum 100-point scale and performed a meta-analysis to assess fatigue severity by subgroups of age, fatigue domain, intervention, case definition, and assessment tool, respectively.

RESULTS

Among the total of 497 relevant studies, 60 RCTs finally met our eligibility criteria, which included a total of 7088 ME/CFS patients (males 1815, females 4532, and no information 741). The fatigue severity of the whole 7,088 patients was 77.9 (95% CI 74.7-81.0), showing 77.7 (95% CI 74.3-81.0) from 54 RCTs in 6,706 adults and 79.6 (95% CI 69.8-89.3) from 6 RCTs in 382 adolescents. Regarding the domain of fatigue, 'cognitive' (74.2, 95% CI 65.4-83.0) and 'physical' fatigue (74.3, 95% CI 68.3-80.3) were a little higher than 'mental' fatigue (70.1, 95% CI 64.4-75.8). The ME/CFS participants for non-pharmacological intervention (79.1, 95% CI 75.2-83.0) showed a higher fatigue level than those for pharmacological intervention (75.5, 95% CI 70.0-81.0). The fatigue levels of ME/CFS patients varied according to diagnostic criteria and assessment tools adapted in RCTs, likely from 54.2 by ICC (International Consensus Criteria) to 83.6 by Canadian criteria and 54.2 by MFS (Mental Fatigue Scale) to 88.6 by CIS (Checklist Individual Strength), respectively.

CONCLUSIONS

This systematic review firstly produced comprehensive features of fatigue severity in patients with ME/CFS. Our data will provide insights for clinicians in diagnosis, therapeutic assessment, and patient management, as well as for researchers in fatigue-related investigations.

"I'm always going to be tired": a qualitative exploration of adolescents' experiences of fatigue in depression

Adolescent depression is a prevalent and disabling condition, but current psychological treatments are only moderately effective. One way to enhance outcomes is to further our understanding of adolescent depression and improve our capacity to target the most frequently reported and problematic symptoms. A common but often neglected symptom of depression is fatigue, which is associated with considerable impairment and has the potential to interfere with adolescents' engagement in psychological therapies. Despite this, the experience of fatigue in adolescent depression and how we target it in treatment is currently poorly understood. Therefore, we aimed to explore adolescents' experiences and understandings of fatigue in depression, recruiting from clinical and community settings. Semi-structured interviews were conducted with 19 UK-based adolescents aged 14-18 years old with elevated symptoms of depression. Using reflexive thematic analysis, three themes were generated. Fatigue is a complex concept explored adolescents' understanding of fatigue as a dynamic, multifaceted symptom which had mental and physical components. Trapped in a cycle of fatigue considered the complex and reciprocal relationship between fatigue and other depressive symptoms, and the subsequent impact of limited energy on engagement with everyday activities. Finally, stigma as a barrier to help-seeking highlighted how adolescents were reluctant to seek help due to experienced stigma and the perception that fatigue was not a serious enough symptom. Findings from this study suggest that fatigue should be viewed as a psychological as well as somatic symptom of depression, with implications regarding the identification and treatment of fatigue in depression in routine clinical practice.

The mediating roles of depressive symptoms and social participation in the relationship between the effects of pain and cognitive function among Chinese older adults: A longitudinal study

Decline in cognitive function poses a substantial burden on individuals, families, and society. However, the longitudinal potential mechanism underlying the link of pain and cognitive function remains unclear. Using data of 4247 participants aged 60 years and over from the China Health and Retirement Longitudinal Study in 2011, 2013, 2018, and 2020, we discussed the longitudinal predictive effect of pain on cognitive function and the mediating effects of depressive symptoms and social participation. The longitudinal mediation model analysis revealed that pain could not directly influence cognitive function, but it could indirectly predict cognitive function through the independent mediation effects of depressive symptoms and social participation. Moreover, the association between pain and cognitive function was serially mediated by depressive symptoms and social participation. Diversified interventions aimed at relieving pain and depressive symptoms, and increasing social participation in older adults would be beneficial for their cognitive function.

Too little or too much: nonlinear relationship between sleep duration and daily affective well-being in depressed adults

BACKGROUND

In addition to having higher negative affect and lower positive affect overall, depressed individuals exhibit heightened affective reactivity to external stimuli than non-depressed individuals. Sleep may contribute to day-to-day fluctuations in depressed individuals, given that sleep disturbance is a common symptom of depression. Yet, little is known about changes in daily affect as a function of nightly sleep duration in depressed adults and non-depressed adults. The current study examined whether and how naturally-occurring sleep duration is associated with negative and positive affect, and how these associations differ between depressed vs. non-depressed adults.

METHODS

Data were drawn from the second wave of the National Study of Daily Experiences (NSDE), a daily diary project of the Midlife in the United States (MIDUS) study. The sample of 2,012 adults (Mage=56.5; 57% female; 84% white) completed eight-day diary interviews via telephone on their daily experiences including nightly sleep duration and negative and positive affect. They also completed assessments of the Composite International Diagnostic Interview-Short form, and depressed status was determined based on DSM-III. Multilevel regression models with linear, quadratic, and cubic terms of sleep duration examined the nonlinear relationship between nightly sleep duration and daily affect. Interaction terms with depression status were added to examine differences between depressed and non-depressed adults.

RESULTS

Depressed adults exhibited significant and greater fluctuations in daily affect as a function of nightly sleep duration than non-depressed adults. Specifically, the degree of decrease in positive affect and increase in negative affect was greater when depressed adults slept 2 or more hours less or longer than their usual sleep hours. Non-depressed adults exhibited relatively stable daily affect regardless of their nightly sleep hours.

CONCLUSIONS

Sleep duration is nonlinearly associated with affect in daily lives of depressed adults, highlighting that both having too little sleep and excessive sleep are associated with adverse daily affective well-being. Implementing sleep interventions to promote an appropriate sleep duration may help improve daily affect among depressed adults.

Celiac disease and depressive disorders as nutritional implications related to common factors - A comprehensive review

Celiac disease (CD) is an immune-mediated disease affecting the small intestine. The only treatment strategy for CD is the gluten-free diet (GFD). One of the more common mental disorders in CD patients is major depressive disorder (MDD). The influence of GFD on the occurrence of MDD symptoms in patients with CD will be evaluated. This diet often reduces nutritional deficiencies in these patients and also helps to reduce depressive symptoms. Both disease entities are often dominated by the same deficiencies of nutrients such as iron, zinc, selenium, iodine, or B and D vitamins. Deficiencies of particular components in CD can favor MDD and vice versa. Gluten can adversely affect the mental state of patients without CD. Also, intestinal microbiota may play an important role in the described process. This work aims to comprehensively assess the common factors involved in the pathomechanisms of MDD and CD, with particular emphasis on nutrient imbalances. Given the complexity of both disease entities, and the many common links, more research related to improving mental health in these patients and the implementation of a GFD would need to be conducted, but it appears to be a viable pathway to improving the quality of life and health of people struggling with CD and MDD. Therefore, probiotics, micronutrients, macronutrients, and vitamin supplements are recommended to reduce the risk of MDD, given that they may alleviate the symptoms of both these disease entities. In turn, in patients with MDD, it is worth considering testing for CD.

Development of a multivariate prediction model for antidepressant resistant depression using reward-related predictors

Introduction

Individuals with depression who do not respond to two or more courses of serotonergic antidepressants tend to have greater deficits in reward processing and greater internalizing symptoms, yet there is no validated self-report method to determine the likelihood of treatment resistance based on these symptom dimensions.

Methods

This online case-control study leverages machine learning techniques to identify differences in self-reported anhedonia and internalizing symptom profiles of antidepressant non-responders compared to responders and healthy controls, as an initial proof-of-concept for relating these indicators to medication responsiveness. Random forest classifiers were used to identify a subset from a set of 24 reward predictors that distinguished among serotonergic medication resistant, non-resistant, and non-depressed individuals recruited online (N = 393). Feature selection was implemented to refine model prediction and improve interpretability.

Results

Accuracies for full predictor models ranged from .54 to .71, while feature selected models retained 3-5 predictors and generated accuracies of .42 to .70. Several models performed significantly above chance. Sensitivity for non-responders was greatest after feature selection when compared to only responders, reaching .82 with 3 predictors. The predictors retained from feature selection were then explored using factor analysis at the item level and cluster analysis of the full data to determine empirically driven data structures.

Discussion

Non-responders displayed 3 distinct symptom profiles along internalizing dimensions of anxiety, anhedonia, motivation, and cognitive function. Results should be replicated in a prospective cohort sample for predictive validity; however, this study demonstrates validity for using a limited anhedonia and internalizing self-report instrument for distinguishing between antidepressant resistant and responsive depression profiles.

Relationship between subjective and objective fatigue and sleep characteristics in individuals with anxiety and mood disorders: An exploratory study

OBJECTIVE

Fatigue and sleep disturbances are important symptoms of anxiety and mood disorders (AMD). Studies about the relationship between these variables usually rely on self-report assessments. Therefore, the aim of our exploratory study was to investigate the independent correlations between subjective and objective fatigue and sleep characteristics in individuals with AMD.

METHODS

In sum, 233 individuals with AMD attending a stress-related disorders day care unit (78.5 % females, mean age 39.0 years old) participated in a cross-sectional study. Participants completed the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Multidimensional Fatigue Inventory-20, and Pittsburgh Sleep Quality Index self-report questionnaires, as well as an exercise capacity workload test for assessing objective fatigue and polysomnography monitoring for evaluation of sleep structure.

RESULTS

In individuals with AMD, exercise capacity workload was associated with lower percent of stage 1 sleep (β = - 0.17, p = 0.006), REM latency (β = -0.13, p = 0.042), and wake after sleep onset (β = -0.12, p = 0.039). General fatigue was associated with a higher percent of body movements (β = 0.12, p = 0.047), as well as mental fatigue was associated with a higher percent of body movements (β = 0.13, p = 0.029), and a higher score on the PSQI (β = 0.21, p = 0.002).

CONCLUSIONS

Objective sleep characteristics were associated with objective assessment of fatigue, while subjective sleep quality was associated with subjectively assessed mental fatigue.

Association between periodontitis and depression severity - A cross-sectional study of the older population in Hamburg

The aim of the current study is to investigate the association between periodontitis (exposure variable) and depression severity (outcome variable) in an older German population. We evaluated data from 6,209 participants (median age 62 years) of the Hamburg City Health Study (HCHS). The HCHS is a prospective cohort study and is registered at ClinicalTrial.gov (NCT03934957). Depression severity were assessed with the 9-item Patient Health Questionnaire (PHQ-9). Periodontal examination included probing depth, gingival recession, plaque index, and bleeding on probing. Descriptive analyses were stratified by periodontitis severity. Multiple linear regression models were adjusted for age, sex, diabetes, education, smoking, and antidepressant medication. Linear regression analyses revealed a significant association between log-transformed depression severity and periodontitis when including the interaction term for periodontitis * age, even after adjusting for age, sex, diabetes, education, smoking and antidepressant medication. We identified a significant association between severe periodontitis and elevated depression severity, which interacts with age. Additionally, we performed a linear regression model for biomarker analyses, which revealed significant associations between depression severity and severe periodontitis with log-transformed inflammatory biomarkers interleukin 6 (IL-6) and high-sensitivity C-reactive protein (hsCRP). In order to identify new therapeutic strategies for patients with depression and periodontal disease, future prospective studies are needed to assess the physiological and psychosocial mechanisms behind this relationship and the causal directionality.

Usability and Acceptability of a Videoconference Program for the Treatment of Depression in Adults With Peripheral Neuropathy

Peripheral neuropathy is a debilitating neurological disorder affecting 13% to 14% of the US population. Estimates for co-occurring mood disorders in individuals with neuropathy range from 30% to 47%, but sparse evidence exists regarding depression treatment for adults with neuropathy. A cognitive-behavioral treatment, Acceptance and commitment therapy, is known to reduce depression in people with chronic pain, but little is known about its effectiveness in adults with neuropathy, particularly when the treatment is provided via videoconference. Acceptability and usability of this therapeutic treatment provided via videoconference was assessed in participants with peripheral neuropathy and symptoms of depression. Participants completed pre- and post-self-report outcome measures: the nine-item depression scale of the Patient Health Questionnaire and the 36-item Short-Form Health Survey. They also completed the Acceptability e-Scale and Post-Study System Usability Questionnaire after treatment. Depression decreased significantly, with scores declining from an average of 9.2 to 5.1 on the Patient Health Questionnaire ( P < .05). The Short-Form Health Survey indicated significant improvement post-treatment on the "Energy/Fatigue" and "Emotional Well Being" subscales. The intervention was rated by participants as acceptable and demonstrated high usability. This initial therapeutic treatment via videoconference offers promise to treat depression in older adults with neuropathy.

Network analysis of comorbid insomnia and depressive symptoms among psychiatric practitioners during the COVID-19 pandemic

STUDY OBJECTIVES

Insomnia and depression are common mental health problems reported by mental health professionals during the COVID-19 pandemic. Network analysis is a fine-grained approach used to examine associations between psychiatric syndromes at a symptom level. This study was designed to elucidate central symptoms and bridge symptoms of a depression-insomnia network among psychiatric practitioners in China. The identification of particularly important symptoms via network analysis provides an empirical foundation for targeting specific symptoms when developing treatments for comorbid insomnia and depression within this population.

METHODS

A total of 10,516 psychiatric practitioners were included in this study. The Insomnia Severity Index (ISI) and 9-item Patient Health Questionnaire (PHQ-9) were used to estimate prevalence rates of insomnia and depressive symptoms, respectively. Analyses also generated a network model of insomnia and depression symptoms in the sample.

RESULTS

Prevalence rates of insomnia (ISI total score ≥8), depression (PHQ-9 total score ≥5) and comorbid insomnia and depression were 22.2% (95% confidence interval: 21.4-22.9%), 28.5% (95% confidence interval: 27.6-29.4%), and 16.0% (95% confidence interval: 15.3-16.7%), respectively. Network analysis revealed that "Distress caused by sleep difficulties" (ISI7) and "Sleep maintenance" (ISI2) had the highest strength centrality, followed by "Motor dysfunction" (PHQ8) and "Sad mood" (PHQ2). Furthermore, the nodes "Sleep dissatisfaction" (ISI4), "Fatigue" (PHQ4), and "Motor dysfunction" (PHQ8) had the highest bridge strengths in linking depression and insomnia communities.

CONCLUSIONS

Both central and bridge symptoms (ie, Distress caused by sleep difficulties, Sleep maintenance, Motor dysfunction, Sad mood, Sleep dissatisfaction, and Fatigue) should be prioritized when testing preventive measures and specific treatments to address comorbid insomnia and depression among psychiatric practitioners during the COVID-19 pandemic.

CITATION

Zhao N, Zhao Y-J, An F, et al. Network analysis of comorbid insomnia and depressive symptoms among psychiatric practitioners during the COVID-19 pandemic. J Clin Sleep Med. 2023;19(7):1271-1279.

The Longitudinal Features of Depressive Symptoms During the COVID-19 Pandemic Among Chinese College Students: A Network Perspective

There is substantial evidence that the Corona Virus Disease 2019 (COVID-19) pandemic increased the risk of depressive symptoms among college students, but the long-term features of depressive symptoms on a symptom level have been poorly described. The current study investigated interaction patterns between depressive symptoms via network analysis. In this longitudinal study, participants included 860 Chinese college students (65.8% female; M_age = 20.6, SD_age = 1.8, range: 17-27) who completed a questionnaire at three-time points three months apart. Results demonstrated that fatigue was the most influential symptom, and the occurrence of fatigue could give rise to other depressive symptoms. In addition to predicting other symptoms, fatigue could be predicted by other symptoms in the measurement. The network structures were similar across time, suggesting that the overall interaction pattern of depressive symptoms was stable over the longitudinal course. These findings suggest that depressive symptoms during the COVID-19 period are associated with the presence of fatigue.

Ventral Tegmental Area M5 Muscarinic Receptors Mediate Effort-Choice Responding and Nucleus Accumbens Dopamine in a Sex-Specific Manner

Optimization of effort-related choices is impaired in depressive disorders. Acetylcholine (ACh) and dopamine (DA) are linked to depressive disorders, and modulation of ACh tone in the ventral tegmental area (VTA) affects mood-related behavioral responses in rats. However, it is unknown if VTA ACh mediates effort-choice behaviors. Using a task of effort-choice, rats can choose to lever press on a fixed-ratio 5 (FR5) schedule for a more-preferred food or consume freely available, less-preferred food. VTA administration of physostigmine (1 μg and 2 μg/side), a cholinesterase inhibitor, reduced FR5 responding for the more-preferred food while leaving consumption of the less-preferred food intact. VTA infusion of the M5 muscarinic receptor negative allosteric modulator VU6000181 (3 μM, 10 μM, 30 μM/side) did not affect lever pressing or chow consumption. However, VU6000181 (30 μM/side) coadministration with physostigmine (2 μg/side) attenuated physostigmine-induced decrease in lever pressing in female and male rats and significantly elevated lever pressing above vehicle baseline levels in male rats. In in vivo voltammetry experiments, VTA infusion of combined physostigmine and VU6000181 did not significantly alter evoked phasic DA release in the nucleus accumbens core (NAc) in female rats. In male rats, combined VTA infusion of physostigmine and VU6000181 increased phasic evoked DA release in the NAc compared with vehicle, physostigmine, or VU6000181 infusion alone. These data indicate a critical role and potential sex differences of VTA M5 receptors in mediating VTA cholinergic effects on effort choice behavior and regulation of DA release. SIGNIFICANCE STATEMENT: Effort-choice impairments are observed in depressive disorders, which are often treatment resistant to currently available thymoleptics. The role of ventral tegmental area (VTA) acetylcholine muscarinic M5 receptors, in a preclinical model of effort-choice behavior, is examined. Using the selective negative allosteric modulator of the M5 receptor VU6000181, we show the role of VTA M5 receptors on effort-choice and regulation of dopamine release in the nucleus accumbens core. This study supports M5 receptors as therapeutic targets for depression.

The efficacy of integrated hepatitis C virus treatment in relieving fatigue in people who inject drugs: a randomized controlled trial

BACKGROUND

Most people who inject drugs (PWIDs) suffer from severe fatigue, and chronic hepatitis C virus (HCV) infection may play a role in this. However, there is scarce evidence about interventions that alleviate fatigue among PWIDs. The present study investigated the effect of integrated HCV treatment on fatigue in this population compared to the effect of standard HCV treatment, adjusted for sustained virological response of the HCV treatment.

METHODS

This multi-center, randomized controlled trial evaluated fatigue as a secondary outcome of integrated HCV treatment (the INTRO-HCV trial). From May 2017 to June 2019, 276 participants in Bergen and Stavanger, Norway, were randomly assigned to receive integrated and standard HCV treatment. Integrated treatment was delivered in eight decentralized outpatient opioid agonist therapy clinics and two community care centers; standard treatment was delivered in specialized infectious disease outpatient clinics at referral hospitals. Fatigue was assessed prior to treatment and 12 weeks after treatment using the nine-item Fatigue Severity Scale (FSS-9). We applied a linear mixed model to evaluate the impact of integrated HCV treatment on changes in FSS-9 (ΔFSS-9) sum scores.

RESULTS

At baseline, the mean FSS-9 sum score was 46 (standard deviation (SD): 15) for participants on integrated HCV treatment and 41 (SD: 16) for those on standard treatment. Twelve weeks after completed HCV treatment, the mean FSS-9 sum score for participants receiving integrated HCV treatment was 42 (SD: 15) and 40 (SD: 14) for those receiving standard HCV treatment. Integrated HCV treatment did not reduce the FSS-9 scores compared to standard HCV treatment (ΔFSS-9: -3.0, 95% confidence interval (CI): -6.4;0.4).

CONCLUSIONS

Fatigue is a common symptom among PWIDs. Integrated HCV treatment is at least equal to standard HCV treatment in improving fatigue.

TRIAL REGISTRATION

ClinicalTrials.gov.no NCT03155906, 16/05/2017.

The Motivation and Energy Inventory (MEI): Analysis of the clinically relevant response threshold in patients with major depressive disorder and emotional blunting using data from the COMPLETE study

BACKGROUND

The Motivation and Energy Inventory (MEI) is a patient-reported scale for assessment of the impact of mental/cognitive energy, social motivation, and physical energy on daily functioning in patients with major depressive disorder (MDD). This analysis was undertaken to establish the clinically relevant response threshold for the MEI in patients with MDD receiving antidepressant treatment.

METHODS

Patients with MDD experiencing inadequate response and emotional blunting on selective serotonin reuptake inhibitor or serotonin-noradrenaline reuptake inhibitor monotherapy (adequate dose for ≥6 weeks) were switched to vortioxetine 10-20 mg/day for 8 weeks. Anchor- and distribution-based methods were used to determine the minimal clinically important difference (MCID) in MEI total score.

RESULTS

After 8 weeks of vortioxetine treatment, mean (standard deviation) change in MEI total score from baseline was 33.0 (27.3) points. At week 8, mean change in MEI total score from baseline was 37.5 (27.8) points in patients no longer reporting emotional blunting and 28.3 (26.2) points in those still experiencing emotional blunting. In patients considered minimally improved (i.e. Clinical Global Impression-Improvement [CGI-I] score of 3 after 8 weeks of vortioxetine), mean change in MEI total score from baseline was 14.7 (19.1) points. In patients defined as responders (CGI-I score of 2 at 8 weeks), mean change in MEI total score was 33.0 (24.7) points.

LIMITATIONS

Short study duration.

CONCLUSIONS

These results provide further validation of the clinical utility of the MEI for assessing treatment response in patients with MDD. The suggested MCID for MEI total score is 15 points.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03835715.

Mental health and fatigue status of the medical workforce during the COVID-19 outbreak in the Yangzhou city, China

Background

When the coronavirus disease 2019 (COVID-19) erupted in Yangzhou, China, at the end of July 2021, medical workers in Yangzhou immediately joined the frontline for the fight against the pandemic. This study aimed to identify the mental health and fatigue experienced by the medical workers in Yangzhou during the COVID-19 outbreak.

Methods

We included 233 medical workers who participated in the front-line work for more than 1 month through the questionnaire, including doctors, nurses, medical technicians and medical students. The generalized anxiety disorder-7 (GAD-7), patient health questionnaire-9 (PHQ-9), and Fatigue self-assessment scale (FSAS) were administered to the participants and their responses were evaluated.

Results

A total of 233 eligible questionnaires were received. Among them, 130 people (57.08%) were probably anxious and 141 (60.52%) people were clinically depressed. Poor sleep was considered an independent risk factor for anxiety (OR = 7.164, 95% CI: 3.365 15.251, p = 0.000) and depression (OR = 6.899, 95% CI: 3.392 14.030, p = 0.000). A high PHQ-9 score was considered an independent risk factor for general fatigue (OR = 1.697, 95% CI: 1.481 1.944, p = 0.000). Mental fatigue (OR = 1.092, 95% CI: 1.027 1.161, p = 0.005) and fatigue response to sleep/rest (OR = 1.043, 95% CI: 1.011 1.076 p = 0.008) were considered independent risk factors for general fatigue.

Conclusion

Poor quality of sleep led to probable anxiety, depression, and general fatigue. Mental fatigue and fatigue response to sleep/rest were independent risk factors for depression, which merits attention for battling COVID-19.

Mental fatigue in individuals with psychiatric disorders: a scoping review

Objective: The aim of this study was to complete a scoping review of the published literature describing the relationship between mental fatigue and various psychiatric disorders, to better understand its frequency and clinical impact, and to provide recommendations for future clinical research.Methods: A scoping review using PubMed/MEDLINE, Cochrane and PsychArticles databases was conducted using the keywords 'mental fatigue', 'mental tiredness' or 'mental exhaustion', and completed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Extension for Scoping Reviews 2018 checklist.Results: We extracted 10 studies fulfilling our inclusion criteria from a total of 2937 publications. Mental fatigue was studied within mood disorders, anxiety disorders, obsessive compulsive disorder and obsessive-compulsive personality disorder. A commonly used tool to measure mental fatigue in these samples was the Multidimensional Fatigue Inventory-20. Specific cognitive factors (unhelpful beliefs about sleep, symptom-focussed rumination) and personality risk factors (harm avoidance, self-directedness, cooperativeness, persistence) were relevant to predicting mental fatigue symptoms and rates of mental fatigue may vary with gender and diagnosis.Conclusion: Research into mental fatigue in adult psychiatric sample was limited to a few psychiatric disorders and requires further investigation.Key pointsA commonly used tool to measure mental fatigue was the Multidimensional Fatigue Inventory-20. However, more research into the validity and reliability for illness specific instruments to measure mental fatigue in psychiatric population is required.Reduction of mental fatigue was associated with improvement on quality of life.Specific cognitive factors (unhelpful beliefs about sleep, symptom-focussed rumination) and personality risk factors (harm avoidance, self-directedness, cooperativeness, persistence) were relevant to predicting mental fatigue symptoms and rates of mental fatigue may vary with gender.Reviewed articles indicated that mental fatigue presence was associated with lower odds of OCD. In addition, the results suggested that mental fatigue symptoms were more common in individuals with OCPD rather than OCD.Research into mental fatigue in adult psychiatric sample was limited to a few psychiatric disorders and requires further investigation to prevent potential misattribution as mental fatigue symptoms overlap between different psychiatric disorders.

Skepticism about Recent Evidence That Psilocybin "Liberates" Depressed Minds

A recent paper in Nature Medicine found that psilocybin therapy in patients with depression decreased brain network modularity (measured with task-free functional magnetic resonance imaging), an effect supposedly not found with the selective serotonin reuptake inhibitor S-citalopram. This decrease in network modularity also correlated with depression. Here, we raise several issues with this paper, including inconsistencies in reports of the primary clinical outcome, statistical flaws including a one-tailed test, nonsignificant interaction, and regression to the mean, the ambiguity and overinterpretation of "resting state" data, and a missing reference for a conceptually similar study that exemplifies why a one-tailed test cannot be justified. Together, these issues make us question the uniqueness and impact of these findings, as well as the unwarranted media hype that they generated.

Vigor, Effort-Related Aspects of Motivation and Anhedonia

In this chapter we provide an overview of the pharmacological and circuit mechanisms that determine the willingness to expend effort in pursuit of rewards. A particular focus will be on the role of the mesolimbic dopamine system, as well the contributing roles of limbic and cortical brains areas involved in the evaluation, selection, and invigoration of goal-directed actions. We begin with a review of preclinical studies, which have provided key insights into the brain systems that are necessary and sufficient for effort-based decision-making and have characterized novel compounds that enhance selection of high-effort activities. Next, we summarize translational studies identifying and expanding this circuitry in humans. Finally, we discuss the relevance of this work for understanding common motivational impairments as part of the broader anhedonia symptom domain associated with mental illness, and the identification of new treatment targets within this circuitry to improve motivation and effort-expenditure.

Gut microbiome and daytime function in Chinese patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is underscored by daytime dysfunction-associated features, including mood disturbances, impaired cognition, fatigue, and daytime sleepiness. Importantly, the gut-brain axis may represent a potential mechanistic link between MDD and daytime dysfunction. Therefore, this study aimed to explore the gut microbiome composition and daytime dysfunction in Chinese patients with MDD.

METHODS

We enrolled 36 patients with MDD and 45 healthy controls (HCs) matched by age, sex, and body mass index (BMI). Daytime function including emotion, fatigue, and sleepiness were assessed using the Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Hamilton Anxiety Scale (HAMA), and Hamilton Depression Scale (HAMD). 16S rRNA sequencing was employed to characterize the gut microbiota in stool samples.

RESULTS

The operational taxonomic units (OTUs) OTU255, OUT363 were positively correlated with HAMD and HAMA. OTU244, OTU542 and OTU221 were positively correlated with ESS, HAMD and HAMA. OTU725 and OTU80 were positively correlated with FSS, ESS, HAMD and HAMA, while OTU423 and OTU502 were negatively correlated with all above. Flavonifractor positively correlated with fatigue in patients with MDD and all individuals simultaneously. The correlation between gut microbiome and daytime function was different in MDD and HCs.

CONCLUSIONS

We identified several OTUs associated with the severity of fatigue, depression, daytime sleepiness and anxiety in all individuals. Our results revealed the differences in microbiome found between patients with MDD and HCs. These findings provide insights into the potential microbiota changes that occur in MDD, and will enable the development of specific therapeutic strategies for targeting the various symptoms of depression.

Validation of the Traditional Chinese Version of the Pittsburgh Fatigability Scale for Older Adults

OBJECTIVES

The Pittsburgh Fatigability Scale (PFS) is a self-administered 10-item tool to measure physical and mental fatigability in older adults. The aim of the current study was to validate the psychometric properties of the traditional Chinese version of PFS (TC-PFS).

METHODS

We recruited 114 community-dwellingolder adults, where 35 were diagnosed with late-life depression (LLD), 26 with mild cognitive impairment (MCI), and 53 were cognitively normal (CN) from a larger community study of older adults. Statistical analyses were done separately for TC-PFS Physical and Mental subscales. Factor analysis was used for reliability, Cronbach's alpha for internal consistency, Pearson's correlation for construct validity, and group comparison for discriminative validity.

RESULTS

Factor analysis revealed a two-factor structure for both the TC-PFS Physical and Mental subscales with high reliability (α = 0.89 and 0.89, respectively). Patients with LLD had the highest PFS scores, with 80.0% and 82.9% classified as having greater physical and mental fatigability. For concurrent validity, we found moderate associations with the vitality and physical functioning subscales of the 36-Item Short Form Health Survey. For convergent validity, TC-PFS showed moderate association with emotional-related psychometrics, particularly for the Physical subscale in those with LLD. In contrast, TC-PFS Mental subscale showed correlations with cognitive function, particularly in the MCI group.

CONCLUSIONS

Our results indicate that the TC-PFS is a valid instrument to measure perceived physical and mental fatigability in older Taiwanese adults.Clinical implications: Perceived fatigability reflects the underlying physical, mental or cognitive function in older adults with or without depression.

Effects of Lower Limb Cycling Training on Different Components of Force and Fatigue in Individuals With Parkinson’s Disease

The strength of lower extremity is important for individuals to maintain balance and ambulation functions. The previous studies showed that individuals with Parkinson’s disease suffered from fatigue and strength loss of central origin. The purpose of this study was to investigate the effect of lower extremities’ cycling training on different components of force and fatigue in individuals with Parkinson’s disease. Twenty-four individuals (13 males, 11 females, mean age: 60.58 ± 8.21 years) diagnosed with idiopathic Parkinson’s disease were randomized into training and control groups. The maximum voluntary contraction (MVC) force, voluntary activation level (VA), and twitch force of knee extensors were measured using a custom-made system with surface electrical stimulation. The general, central, and peripheral fatigue indexes (GFI, CFI, and PFI) were calculated after a fatiguing cycling protocol. Subjects received 8 weeks of low resistance cycling training (training group) or self-stretching (control group) programs. Results showed that MVC, VA, and twitch force improved (p < 0.05) only in the training group. Compared to the baseline, central fatigue significantly improved in the training group, whereas peripheral fatigue showed no significant difference in two groups. The cycling training was beneficial for individuals with Parkinson’s disease not only in muscle strengthening but also in central fatigue alleviation. Further in-depth investigation is required to confirm the effect of training and its mechanism on central fatigue.

A Systematic Review and Individual Patient Data Network Analysis of the Residual Symptom Structure Following Cognitive-Behavioral Therapy and Escitalopram, Mirtazapine and Venlafaxine for Depression

OBJECTIVE

Consistent evidence suggests residual depressive symptomology are the strongest predictors of depression relapse following cognitive-behavioral therapy (CBT) and antidepressant medications (ADM's). Psychometric network models help detecting and understanding central symptoms that remain post-treatment, along with their complex co-occurrences. However, individual psychometric network studies show inconsistent findings. This systematic review and IPD network analysis aimed to estimate and compare the symptom network structures of residual depressive symptoms following CBT, ADM's, and their combination.

METHODS

PsycINFO, PsycArticles, and PubMed were systematically searched through October 2020 for studies that have assessed individuals with major depression at post-treatment receiving either CBT and/or ADM's (venlafaxine, escitalopram, mirtazapine). IPD was requested from eligible samples to estimate and compare residual symptom psychometric network models post-CBT and post-ADM's.

RESULTS

In total, 25 from 663 eligible samples, including 1,389 patients qualified for the IPD. Depressed mood and anhedonia were consistently central residual symptoms post-CBT and post-ADM's. For CBT, fatigue-related and anxiety symptoms were also central post-treatment. A significant difference in network structure across treatments (CBT vs. ADM) was observed for samples measuring depression severity using the MADRS. Specifically, stronger symptom occurrences were present amongst lassitude-suicide post-CBT (vs. ADM's) and amongst lassitude-inability to feel post-ADM's (vs. CBT). No significant difference in global strength was observed across treatments.

CONCLUSIONS

Core major depression symptoms remain central across treatments, strategies to target these symptoms should be considered. Anxiety and fatigue related complaints also remain central post-CBT. Efforts must be made amongst researchers, institutions, and journals to permit sharing of IPD.Systematic Review Registration: A protocol was prospectively registered on PROSPERO (CRD42020141663; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=141663).

Efficacy of Qigong Exercise for Treatment of Fatigue: A Systematic Review and Meta-Analysis

Objective: Several studies suggested that Qigong exercise (QE) can relieve fatigue in patients diagnosed with various diseases. Our review aimed to evaluate the efficacy of QE for alleviating fatigue. Methods: A related literature search was performed in the PubMed, Web of Science, Embase, Cochrane Library, China Biology Medicine disc (CBM), China National Knowledge Infrastructure (CNKI), Wanfang, and VIP data bases from inception to November 2020. Information on fatigue, malaise, tiredness, and Qigong research data was collected. Results: Sixteen randomized controlled trials (RCTs) were reported in patients with cancer (n = 4), chronic fatigue syndrome (n = 2), and other diseases (n = 10). The QE groups showed significant improvements in total fatigue intensity [15 RCTs, p < 0.00001; standard mean difference (SMD) -0.69 (-0.95 to -0.44)]. The QE groups did not show significant improvement in quality of life [4 RCTs, p = 0.08; SMD 0.53 (-0.07 to 1.14)]. The statistically significant difference of the subgroup analyses (different primary diseases, QE types, and study quality) also remained unchanged. Conclusion: The findings of this meta-analysis indicate that QE may be beneficial for improving fatigue in patients diagnosed with various diseases. Considering the limitations of the study, we draw a very cautious conclusion regarding the resulting estimate of the effect. Further studies are warranted to better understand the benefits of QE in primary medical care.

Patient Expectations and Experiences of Antidepressant Therapy for Major Depressive Disorder: A Qualitative Study

PURPOSE

This qualitative study explored patient perceptions of the most burdensome symptoms of major depressive disorder (MDD), the impact of symptoms on patients' daily lives, and patient expectations and experiences regarding the timing of onset of antidepressant pharmacotherapy.

PATIENTS AND METHODS

Data were collected through facilitated, patient focus-group sessions in the USA between May and June 2019. Participants were adults with confirmed MDD who reported a major depressive episode within the past 2 years, for which they had received pharmacologic treatment for ≥6 weeks. The semi-structured discussion focused on the key topics of bothersome symptoms of MDD, the impact of symptoms on quality of life, and the effects of antidepressant treatment. Interviews were audio-recorded; findings were summarized using a content-analysis approach.

RESULTS

Five focus-group sessions were undertaken, involving a total of 29 patients (each attended one session; mean age, 43.4 years; 72.4% female). Mean time since confirmed diagnosis of MDD was 13.1 years. The most commonly prescribed antidepressants received were bupropion (41.4% of participants), escitalopram (34.5%), and sertraline (34.5%). The most frequently reported bothersome MDD symptoms were fatigue (mentioned by 58.6% of participants), lack of motivation/loss of interest (51.7%), anxiety/panic (44.8%), sadness (41.4%), and lack of concentration/brain fog (41.4%). Socialization, family life, and work were the areas in which quality of life was most impacted. Participants expressed dissatisfaction with their antidepressant treatment. Fast symptom resolution was mentioned as a priority (defined as <1 week by 38.5% of participants and ≤1 month by 65.4%). Most participants had not experienced fast relief from their symptoms with current or previous antidepressant medications.

CONCLUSION

Results of this qualitative study suggest that fatigue, anhedonia, cognitive symptoms, and anxiety are some of the most bothersome symptoms for patients with MDD and highlight the importance of obtaining rapid relief from these symptoms in order to improve outcomes and patient satisfaction with antidepressant medication.

Fatigue and brain arousal in patients with major depressive disorder

Fatigue is considered a key symptom of major depressive disorder (MDD), yet the term lacks specificity. It can denote a state of increased sleepiness and lack of drive (i.e., downregulated arousal) as well as a state of high inner tension and inhibition of drive with long sleep onset latencies (i.e., upregulated arousal), the latter typically found in depression. It has been proposed to differentiate fatigue along the dimension of brain arousal. We investigated whether such stratification within a group of MDD patients would reveal a subgroup with distinct clinical features. Using an automatic classification of EEG vigilance stages, an arousal stability score was calculated for 15-min resting EEGs of 102 MDD patients with fatigue. 23.5% of the patients showed signs of hypoarousal with EEG patterns indicating drowsiness or sleep; this hypoaroused subgroup was compared with remaining patients (non-hypoaroused subgroup) concerning self-rated measures of depressive symptoms, sleepiness, and sleep. The hypoaroused subgroup scored higher on the Beck Depression Inventory items "loss of energy" (Z = - 2.13, p = 0.033; ɳ² = 0.044, 90% CI 0.003-0.128) and "concentration difficulty" (Z = - 2.40, p = 0.017; ɳ² = 0.056, 90% CI 0.009-0.139), and reported higher trait and state sleepiness (p < 0.05) as compared to the non-hypoaroused group. The non-hypoaroused subgroup, in contrast, reported more frequently the presence of suicidal ideation (Chi² = 3.81, p = 0.051; ɳ² = 0.037, 90% CI 0.0008-0.126). In this study, we found some evidence that stratifying fatigued MDD patients by arousal may lead to subgroups that are pathophysiologically and clinically more homogeneous. Brain arousal may be a worth while target in clinical research for better understanding the mechanisms underlying suicidal tendencies and to improve treatment response.

Current Clinical Psychopharmacology in Borderline Personality Disorder

BACKGROUND

Patients with Borderline Personality Disorder (BPD) manifest affective and behavioral symptoms causing personal distress, relationship difficulties, and reduced quality of life with global functioning impairment, mainly when the disease takes an unfavorable course. A substantial amount of healthcare costs is dedicated to addressing these issues. Many BPD patients receive medications, mostly those who do not respond to psychological interventions.

OBJECTIVE

Our aim was to assess the efficacy of the most used strategies of pharmacological interventions in BPD with a comprehensive overview of the field.

METHODS

We searched the PubMed database for papers focused on the most used psychotropic drugs for BPD. We included randomized controlled trials and open studies in adult patients with BPD, focusing on the efficacy and tolerability of single classes of drugs with respect to specific clinical presentations that may occur during the course of BPD.

RESULTS

Specific second-generation antipsychotics (SGAs) or serotonergic antidepressants can be effective for different core symptoms of BPD, mainly including mood symptoms, anxiety, and impulse dyscontrol. Some atypical antipsychotics can also be effective for psychotic and dissociative symptoms. Specific antiepileptics can be useful in some cases in treating different BPD symptoms, mainly including mood instability, impulsiveness, and anger.

CONCLUSION

No medication is currently approved for BPD, and clinicians should carefully assess the benefits and risks of drug treatment. Further studies are needed to identify specific personalized treatment strategies, also considering the clinical heterogeneity and possible comorbidities of BPD.

Comparison of Thyroid Hormone Levels Between Patients With Major Depressive Disorder and Healthy Individuals in China

Abnormal thyroid function in major depressive disorder (MDD) has been studied extensively, but the results still remain inconsistent. In China, few large-scale studies have investigated the differences in the levels of thyroid hormones between patients with MDD and healthy controls (HCs). In this retrospective, cross-sectional study, 535 MDD patients and 998 HCs were included. We compared the levels of thyroid hormones (FT3, FT4, and TSH) between the two groups, as well as investigated the distribution of levels of thyroid hormones within and outside normal ranges. The results showed that all the three hormones were significantly lower in MDD patients than in HCs, which was also true in different gender and age subgroups. The proportion of subjects with levels of all the three hormones outside the normal range in the MDD group was higher than that in the HC group (all p < 0.05). However, no significant difference was found in clinical/subclinical hyperthyroidism or hypothyroidism between the two groups (p > 0.05). Our study showed that the levels of thyroid hormones were lower in MDD patients, suggesting that there was an association between abnormal thyroid function and depression. The higher rate of thyroid dysfunction in MDD patients indicated the importance of regular monitoring of thyroid function.

Ginsenoside Rb1 exerts antidepressant-like effects via suppression inflammation and activation of AKT pathway

Depression-like behaviors caused by chronic stress are related to inflammation and microglia activation. Antidepressant therapy may contribute to inhibiting inflammation responses and microglia activation. Ginsenoside Rb1 (GRb1) is known to display antidepressant-like effect on chronic unpredictable mild stress-induced depressive rats. However, the antidepressant-like effects of GRb1 on chronic restraint stress (CRS) mice and the potential anti-inflammatory mechanisms are unclear. Here, we focused on the molecular mechanisms related to inhibition of inflammation response and the protection on microglia. Our results showed that GRb1 had an antidepressant effects via relieving the depression-like behaviors in CRS model. Furthermore, GRb1 increased the protein expressions of brain-derived neurotrophic factor and phospho- protein kinase B/ protein kinase B (p-AKT/AKT), and decreased the protein expressions of interleukin-1β (IL-1β), tumor necrosis factor α (TNF-α) and ionized calcium binding adapter molecule 1 in hippocampus, reduced the levels IL-1β and TNF-α in serum. Finally, GRb1 lowered the protein expressions of IL-1β and TNF-α in BV-2 microglia induced by lipopolysaccharides. Taken together, the results indicate that GRb1 prevents CRS-induced depression-like behaviors in mice, which may be related to anti-inflammatory effects in hippocampus, serum and microglia and activation of AKT pathway.

Prevalence and correlates of fatigue and its association with quality of life among clinically stable older psychiatric patients during the COVID-19 outbreak: a cross-sectional study

Background

The pattern of fatigue in older psychiatric patients during the COVID-19 outbreak was unknown. This study examined the prevalence of fatigue and its association with overall quality of life (overall QOL) in clinically stable older patients with psychiatric disorders during the COVID-19 outbreak.

Methods

This was a multicenter, cross-sectional study. Fatigue, depressive symptoms, pain, insomnia symptoms, and overall QOL were assessed with standardized instruments.

Results

A total of 1063 patients were recruited. The prevalence of fatigue was 47.1% (95%CI: 44.1–50.1%). An analysis of covariance revealed that overall QOL was significantly lower in patients with fatigue compared to those without (P = 0.011). A multiple logistic regression analysis revealed that more severe depressive symptoms (OR = 1.15, P < 0.001), insomnia symptoms (OR = 1.08, P < 0.001) and pain (OR = 1.43, P < 0.001) were significantly associated with fatigue.

Conclusions

Fatigue is common among clinically stable older patients with psychiatric disorders during the COVID-19 outbreak. Considering its negative impact on overall QOL, regular assessment of fatigue and appropriate treatment warrant attention in this subpopulation.

Behavioral and dopamine transporter binding properties of the modafinil analog (S, S)-CE-158: reversal of the motivational effects of tetrabenazine and enhancement of progressive ratio responding

RATIONALE

Atypical dopamine (DA) transport blockers such as modafinil and its analogs may be useful for treating motivational symptoms of depression and other disorders. Previous research has shown that the DA depleting agent tetrabenazine can reliably induce motivational deficits in rats, as evidenced by a shift towards a low-effort bias in effort-based choice tasks. This is consistent with human studies showing that people with major depression show a bias towards low-effort activities.

OBJECTIVES

Recent studies demonstrated that the atypical DA transport (DAT) inhibitor (S)-CE-123 reversed tetrabenazine-induced motivational deficits, increased progressive ratio (PROG) lever pressing, and increased extracellular DA in the nucleus accumbens. In the present studies, a recently synthesized modafinil analog, (S, S)-CE-158, was assessed in a series of neurochemical and behavioral studies in rats.

RESULTS

(S, S)-CE-158 demonstrated the ability to reverse the effort-related effects of tetrabenazine and increase selection of high-effort PROG lever pressing in rats tested on PROG/chow feeding choice task. (S, S)-CE-158 showed a high selectivity for inhibiting DAT compared with other monoamine transporters, and systemic administration of (S, S)-CE-158 increased extracellular DA in the nucleus accumbens during the behaviorally active time course, which is consistent with the effects of (S)-CE-123 and other DAT inhibitors that enhance high-effort responding.

CONCLUSIONS

These studies provide an initial neurochemical characterization of a novel atypical DAT inhibitor, and demonstrate that this compound is active in models of effort-related choice. This research could contribute to the development of novel compounds for the treatment of motivational dysfunctions in humans.

Depression development: From lifestyle changes to motivational deficits

Until now, depression research has taken a surprisingly narrow approach to modelling the disease, mainly focusing on some form of psychomotor retardation within a mechanistic framework of depression etiology. However, depression has many symptoms and each is associated with a vast number of substrates. Thus, to deepen our insights, this SI ("Depression Symptoms") reviewed the behavioral and neurobiological sequelae of individual symptoms, specifically, psychomotor retardation, sadness, low motivation, fatigue, sleep/circadian disruption, weight/appetite changes, and cognitive affective biases. This manuscript aims to integrate the most central information provided by the individual reviews. As a result, a dynamic model of depression development is proposed, which views depression as a cumulative process, where different symptoms develop at different stages, referred to as early, intermediate, and advanced, that require treatment with different pharmaceutical agents, that is, selective serotonin reuptake inhibitors early on and dopamine-based antidepressants at the advanced stage. Furthermore, the model views hypothalamic disruption as the source of early symptoms and site of early intervention. Longitudinal animal models that are capable of modelling the different stages of depression, including transitions between the stages, may be helpful to uncover novel biomarkers and treatment approaches.

Fatigue in Cancer and Neuroinflammatory and Autoimmune Disease: CNS Arousal Matters

The term fatigue is not only used to describe a sleepy state with a lack of drive, as observed in patients with chronic physical illnesses, but also a state with an inhibition of drive and central nervous system (CNS) hyperarousal, as frequently observed in patients with major depression. An electroencephalogram (EEG)-based algorithm has been developed to objectively assess CNS arousal and to disentangle these pathophysiologically heterogeneous forms of fatigue. The aim of this study was to test the hypothesis that fatigued patients with CNS hyperarousal score higher on depressive symptoms than those without this neurophysiological pattern.

METHODS

Subjects with fatigue (Multidimensional Fatigue Inventory sum-score > 40) in the context of cancer, neuroinflammatory, or autoimmune diseases were drawn from the 60+ cohort of the Leipzig Research Center for Civilization Diseases. CNS arousal was assessed by automatic EEG-vigilance stage classification using the Vigilance Algorithm Leipzig (VIGALL 2.1) based on 20 min EEG recordings at rest with eyes closed. Depression was assessed by the Inventory of Depressive Symptomatology (IDS-SR).

RESULTS

Sixty participants (33 female; median age: 67.5 years) were included in the analysis. As hypothesized, fatigued patients with CNS hyperarousal had higher IDS-SR scores than those without hyperarousal (F_1,58 = 18.34; p < 0.0001, η² = 0.240).

CONCLUSION

hyperaroused fatigue in patients with chronic physical illness may be a sign of comorbid depression.

Moxibustion at 'Danzhong' (RN17) and 'Guanyuan' (RN4) for fatigue symptom in patients with depression: Study protocol clinical trial (SPIRIT Compliant)

BACKGROUND

Fatigue is one of the most prevalent and debilitating symptoms of major depressive disorder (MDD). The effective management of depression-related fatigue has an important impact on the patient's abilities, functioning, and quality of life (QOL). Moxibustion has been widely used in Traditional Chinese Medicine to manage fatigue. Recent studies have also demonstrated that moxibustion is effective for treating cancer-related fatigue and chronic fatigue syndrome. However, there is not sufficient data supporting the effect of moxibustion for depression-related fatigue. Therefore, this randomized, assessor-blinded, wait-list controlled trial is designed to evaluate the effectiveness, safety, and feasibility of moxibustion treatment for depression-related fatigue.

METHODS

One hundred and seventy-six participants who meet the diagnostic criteria for depression in the International Classification of Diseases, tenth revision (ICD-10), and who also have a score of ≥1 on the 13 item of the Hamilton Depression Rating Scale-17 (HAMD-17), will be enrolled. At study entry, participants will undergo anti-depressant treatment for at least 1 month. Then those who still have a score of ≥1 on the 13 item of the HAMD-17 will be randomly allocated to either a moxibustion group or wait-list control group in a ratio of 1:1. Anti-depressants will be provided for both groups during the whole process of the study period. Participants in the moxibustion group will undergo 14 sessions of moxibustion (over 2 weeks) with anti-depressant treatment, and participants in the wait-list control group will receive only anti-depressant treatment. Subsequently, participants in the moxibustion group will be followed-up for 4 weeks. The primary outcome measure will be the Fatigue Severity Scale (FSS). The secondary outcome measure will be the HAMD-17. Safety will be assessed by monitoring adverse events during the study. Trial feasibility will also be assessed in this study.

DISCUSSION

The results of this study may provide evidence for the efficacy of moxibustion as an adjunct to antidepressants for depression-related fatigue, and promote a more widespread foundation for the selection of moxibustion in the clinical setting as well as for future research in moxibustion therapy.

TRIAL REGISTRATION

This study protocol was registered at the Chinese Clinical Trial Registry (ChiCTR1800016905).

Addressing sleep problems and fatigue within child and adolescent mental health services: A qualitative study

BACKGROUND

Both fatigue and sleep difficulties are common symptoms of mental health presentations such as depression and anxiety. Despite this, little is known about how psychologists in Child and Adolescent Mental Health Services (CAMHS) assess and treat these common symptoms.

METHOD

Qualitative interviews with nine psychologists working in CAMHS analysed using thematic analysis.

RESULTS

Fatigue and sleep problems do not tend to be the focus of assessment because they are seen to be part of other presentations and not accorded priority. Psychologists struggled to differentiate fatigue from sleep problems, with greater clarity about sleep problems, which appear to be more routinely assessed. A number of barriers to addressing fatigue and sleep problems were identified, including lack of motivation from young people to make behavioural changes to address fatigue and/or sleep difficulties. Psychologists wished for more training, access to information for young people and families and more service integration with paediatric physical health settings.

CONCLUSION

Sleep problems and fatigue may not be thoroughly assessed and addressed in CAMHS and are often conflated, with the focus on enquiring about sleep, not fatigue. Further research is required to elucidate whether the themes identified are more pervasive. Potential interventions include training and information provision.

Gut Microbiota in Alzheimer's Disease, Depression, and Type 2 Diabetes Mellitus: The Role of Oxidative Stress

Gut microbiota consists of over 100 trillion microorganisms including at least 1000 different species of bacteria and is crucially involved in physiological and pathophysiological processes occurring in the host. An imbalanced gastrointestinal ecosystem (dysbiosis) seems to be a contributor to the development and maintenance of several diseases, such as Alzheimer's disease, depression, and type 2 diabetes mellitus. Interestingly, the three disorders are frequently associated as demonstrated by the high comorbidity rates. In this review, we introduce gut microbiota and its role in both normal and pathological processes; then, we discuss the importance of the gut-brain axis as well as the role of oxidative stress and inflammation as mediators of the pathological processes in which dysbiosis is involved. Specific sections pertain the role of the altered gut microbiota in the pathogenesis of Alzheimer's disease, depression, and type 2 diabetes mellitus. The therapeutic implications of microbiota manipulation are briefly discussed. Finally, a conclusion comments on the possible role of dysbiosis as a common pathogenetic contributor (via oxidative stress and inflammation) shared by the three disorders.

Animal models of fatigue in major depressive disorder

Fatigue is common in a host of neurological and psychiatric disorders including depression and often continues unabated even after primary symptoms of disease are treated. Its high estimated prevalence combined with the lack of effective medicines has engaged the preclinical research community to search for fatigue models. The present review briefly summarizes the most common animal models that have been brought forward along with some of the associated pharmacological validation data. Like all preclinical models, these models have issues that need to be appreciated in the generation and interpretation of data for the purposes of translation to human disease; specifically, there are deficiencies in construct validity, a lack of medicines that effectively address residual fatigue symptoms, and difficulties in defining specificity with respect to drug effects on fatigue per se. Nonetheless, existing animal models of fatigue arguably serve the valuable purpose of encouraging research in this large area of unmet medical need. Data from these models are predicted to engender human experimentation and the further development of improved model systems.