Outcome profiles in the treatment of unipolar depression

Residual symptoms of depression: clinical and theoretical implications

Residual symptoms of variable intensity often persist following pharmaco/or psychotherapeutic interventions for treatment of major depression (MD). In several studies, such persistent symptoms have been clearly shown to be associated with a higher risk of relapse, chronicity and functional impairment, but their true nature is still controversial. Several authors consider that these symptoms belong to the range of depression proper and thus indicate that the current episode has been inadequately treated, a hypothesis reinforced by their frequent similarity with the symptoms preceding the full-blown picture of MD. However, in the current state of research, their connection with certain personality traits or comorbid disorders—notably anxiety disorders—cannot be completely ruled out. This article reviews the main data from the literature concerning residual symptoms and their treatment, as well as the issues related to their psychopathological meaning. In practice, once the state of a patient has been stabilized in partial remission of the depressive syndrome, the clinician should revise the current therapeutic strategy and seek to find how to return as fully as possible to the previous euthymic state.

Personality traits and escitalopram treatment outcome in major depression

BACKGROUND

Selective serotonin re-uptake inhibitors (SSRI) have proven to be effective in treatment of depression. Still, treatment efficacy varies significantly from patient to patient and about 40% of patients do not respond to initial treatment. Personality traits have been considered one source of variability in treatment outcome.

AIM

Current study aimed at identifying specific personality traits that could be predictive of treatment response and/or the dynamics of symptom change in depressive patients.

METHOD

In a sample of 132 outpatients with major depressive disorder (MDD) treated with an SSRI-group antidepressant escitalopram, the Swedish universities Scales of Personality (SSP) were used in order to find predictive personality traits. For the assessment of the severity of depressive symptoms and the improvement rates, the Hamilton Depression Scale (HAM-D) and Montgomery-Åsberg Depression Rating Scale (MADRS) were used.

RESULTS

Escitalopram-treated MDD patients with higher social desirability achieved more rapid decrease in symptom severity. None of the studied traits predicted the end result of the treatment.

CONCLUSION

The findings suggest that specific personality traits may predict the trajectory of symptom change rather than the overall improvement rate.

For Whom Does Mindfulness-Based Stress Reduction Work? Moderating Effects of Personality

The aim of the present study was to examine potentially moderating effects of personality characteristics regarding changes in anxious and depressed mood associated with Mindfulness-Based Stress Reduction (MBSR), controlling for socio-demographic factors. Meditation-naïve participants from the general population self-presenting with psychological stress complaints (n = 167 participants, 70% women, mean age 45.8 ± 9.3 years) were assessed in a longitudinal investigation of change in mood before and after the intervention and at a 3-month follow-up. Participants initially scoring high on neuroticism showed stronger decreases in both anxious and depressed mood (both p < 0.001). However, when controlled for baseline mood, only the time by neuroticism interaction effect on anxiety remained significant (p = 0.001), reflecting a smaller decrease in anxiety between pre- and post-intervention but a larger decrease in anxiety between post-intervention and follow-up in those with higher baseline neuroticism scores. Most personality factors did not show moderating effects, when controlled for baseline mood. Only neuroticism showed to be associated with delayed benefit. Results are discussed in the context of findings from similar research using more traditional cognitive-behavioral interventions.

Technology Dependence in Home Care: Impact on Patients and Their Family Caregivers

BACKGROUND

The purpose of this review is to explore how home technology care affects patients, family caregivers, and quality of life (QOL).

METHODS

A literature search was conducted to identify studies of home parenteral nutrition (HPN) and other technology prescribed home care.

RESULTS

Technology dependence influences health-related QOL. Patients and their family caregivers must balance the positive aspects of being in the home environment with the challenges of administering complex therapies at home. Patients and caregivers need additional support to reduce the physical, emotional, social, and financial burdens they experience.

CONCLUSIONS

More research is needed to address effective interventions to reduce patient and caregiver burdens and to improve outcomes for technology-dependent individuals. A greater level of preparedness for managing home technology and technology-related problems may improve quality of life.

Amitriptyline versus placebo for major depressive disorder

BACKGROUND

Amitriptyline is a tricyclic antidepressant that was synthesised in 1960 and introduced as early as 1961 in the USA, but is still regularly used. It has also been frequently used as an active comparator in trials on newer antidepressants and can therefore be called a 'benchmark' antidepressant. However, its efficacy and safety compared to placebo in the treatment of major depression has not been assessed in a systematic review and meta-analysis.

OBJECTIVES

To assess the effects of amitriptyline compared to placebo or no treatment for major depressive disorder in adults.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) to August 2012. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). The reference lists of reports of all included studies were screened and manufacturers of amitriptyline contacted for details of additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing amitriptyline with placebo or no treatment in patients with major depressive disorder as diagnosed by operationalised criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. For dichotomous data, we calculated the odds ratio (OR) with 95% confidence intervals (CI). We analysed continuous data using standardised mean differences (with 95% CI). We used a random-effects model throughout.

MAIN RESULTS

The review includes 39 trials with a total of 3509 participants. Study duration ranged between three and 12 weeks. Amitriptyline was significantly more effective than placebo in achieving acute response (18 RCTs, n = 1987, OR 2.67, 95% CI 2.21 to 3.23). Significantly fewer participants allocated to amitriptyline than to placebo withdrew from trials due to inefficacy of treatment (19 RCTs, n = 2017, OR 0.20, 95% CI 0.14 to 0.28), but more amitriptyline-treated participants withdrew due to side effects (19 RCTs, n = 2174, OR 4.15, 95% CI 2.71 to 6.35). Amitriptyline also caused more anticholinergic side effects, tachycardia, dizziness, nervousness, sedation, tremor, dyspepsia, sedation, sexual dysfunction and weight gain. In subgroup and meta-regression analyses the results of the primary outcome were robust towards publication year (1971 to 1997), mean participant age at baseline, mean amitriptyline dose, study duration in weeks, pharmaceutical sponsor, inpatient versus outpatient setting and two-arm versus three-arm design. However, higher severity at baseline was associated with higher superiority of amitriptyline (P = 0.02), while higher responder rates in the placebo groups were associated with lower superiority of amitriptyline (P = 0.05). The results of the primary outcome were rather homogeneous, reflecting comparability of the trials. However, methods of randomisation, allocation concealment and blinding were usually poorly reported. Not all studies used intention-to-treat analyses and in many of them standard deviations were not reported and often had to be imputed. Funnel plots suggested a possible publication bias, but the trim and fill method did not change the overall effect size much (seven adjusted studies, OR 2.64, 95% CI 2.24 to 3.10).

AUTHORS' CONCLUSIONS

Amitriptyline is an efficacious antidepressant drug. It is, however, also associated with a number of side effects. Degree of placebo response and severity of depression at baseline may moderate drug-placebo efficacy differences.

Evaluation of psychodynamic psychotherapy in a community mental health center

This study describes an evaluation of the effectiveness of psychodynamic psychotherapy provided in an outpatient community mental health clinic. The study used a single group pretest-posttest design involving 78 clients. Clinical outcomes included overall psychosocial functioning and quality of life, level of subjective distress, interpersonal functioning and role functioning, measured by the Outcome Questionnaire (Lambert, Hansen, Umpress, Lunnen Okilshi, & Burlingame, 2000). Clients showed statistically significant improvement from pretest (first sessions) to completion of treatment in overall functioning, and quality of life, level of subjective distress, interpersonal functioning and role functioning. Eighty-five percent of clients made statistically and clinically significant change. Calculation of effect sizes for each outcome found moderate to strong change effects ranging from d = .4 to .9. The study illustrates a method of intervention research that therapists and agencies can use to integrate practical evaluation methods into their clinical services in order to improve mental health service to clients, to demonstrate the effectiveness of interventions, and to provide data to support coverage for needed services for clients.

Relaxation for depression

BACKGROUND

Many members of the public have negative attitudes towards antidepressants. Psychological interventions are more acceptable but require considerable therapist training. Acceptable psychological interventions that require less training and skill are needed to ensure increased uptake of intervention. A potential intervention of this sort is relaxation techniques.

OBJECTIVES

To determine whether relaxation techniques reduce depressive symptoms and improve response/remission.

SEARCH STRATEGY

The register of trials kept by the Cochrane Collaboration Depression, Anxiety and Neurosis Group was searched up to February 2008. We also searched the reference lists of included studies.

SELECTION CRITERIA

Studies were included if they were randomised or quasi-randomised controlled trials of relaxation techniques (progressive muscle relaxation, relaxation imagery, autogenic training) in participants diagnosed with depression or having a high level of depression symptoms. Self-rated and clinician-rated depression scores and response/remission were the primary outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers selected the trials, assessed the quality and extracted trial and outcome data, with discrepancies resolved by consultation with a third. Trial authors were approached for missing data where possible and missing data were estimated or imputed in some cases. Continuous measures were summarised using standardised mean differences and dichotomous outcomes by risk ratios.

MAIN RESULTS

There were 15 trials with 11 included in the meta-analysis. Five trials showed relaxation reduced self-reported depression compared to wait-list, no treatment, or minimal treatment post intervention (SMD -0.59 (95% CI -0.94 to -0.24)). For clinician-rated depression, two trials showed a non-significant difference in the same direction (SMD -1.35 (95% CI -3.06 to 0.37)).Nine trials showed relaxation produced less effect than psychological (mainly cognitive-behavioural) treatment on self-reported depression (SMD = 0.38 (95% CI 0.14 to 0.62)). Three trials showed no significant difference between relaxation and psychological treatment on clinician-rated depression at post intervention (SMD 0.29 (95% CI -0.18 to 0.75)).Inconsistent effects were found when comparing relaxation training to medication and there were few data available comparing relaxation with complementary and lifestyle treatments.

AUTHORS' CONCLUSIONS

Relaxation techniques were more effective at reducing self-rated depressive symptoms than no or minimal treatment. However, they were not as effective as psychological treatment. Data on clinician-rated depressive symptoms were less conclusive. Further research is required to investigate the possibility of relaxation being used as a first-line treatment in a stepped care approach to managing depression, especially in younger populations and populations with subthreshold or first episodes of depression.

Severity and duration of depression, not personality factors, predict short term outcome in the treatment of major depression

BACKGROUND

Prediction of treatment outcome has important clinical consequences. Personality factors have rarely been tested as predictors of acute outcome. Personality, demographic and illness-related characteristics were assessed at baseline for prediction of outcome of treatment in depressed out-patients.

METHODS

One hundred and ninety-three patients with major depressive disorder (MDD) were enrolled in a 12 to 16 week trial. The treatment consisted of nefazodone, nefazodone in combination with interpersonal psychotherapy (IPT), IPT in combination with placebo and IPT alone. Demographic and illness related variables were collected at baseline. Personality was assessed using the NEO-FFI. This instrument measures five dimensions of personality. A hierarchical logistic regression was carried out to test for significant predictors of remittance. Further a multiple regression analysis was used to investigate variables predictive of changes on the Hamilton Depression Rating Scale as dependent variable.

RESULTS

Univariate analysis showed a significant relationship of outcome with severity, duration of index episode, and use of medical services (UMS). None of the personality variables was predictive of outcome. Regression analyses showed that these disease related variables each uniquely predicted outcome, but that personality factors did not significantly contribute to the prediction model.

LIMITATIONS

The study was carried out in secondary and tertiary care centers and may not be generalizable to other populations. Personality dimensions were assessed with a self-report instrument and may be prone to bias.

CONCLUSIONS

Severity and duration of the index episode, and to a lesser extent, UMS, and not personality factors, predict outcome in the short term treatment of MDD.

Early response in psychotherapy: Further evidence for the importance of common factors rather than “placebo effects”

Evidence is presented demonstrating that placebo control groups benefit more from psychotherapy than no-treatment control groups but less than patients who receive theory-driven treatments. Through a brief review of the results of comparative outcome studies, studies which compare patient outcomes for those seen by trainees or paraprofessionals versus professional therapists and those which show an early response of a sizable portion of patients, a case is made for the powerful effects of common factors in psychotherapy. The early response phenomenon has proposed another challenge to the unique effects of specific psychotherapies and to the wisdom of emphasizing the causative effects of specific techniques in the treatment of specific disorders.

Neuroticism and Longitudinal Change in Caregiver Depression: Impact of a Spouse-Caregiver Intervention Program

PURPOSE

We examined the impact of caregiver neuroticism on longitudinal change in depression among spouse-caregivers of individuals with Alzheimer's disease receiving either enhanced psychosocial treatment or usual care. We were interested in whether high levels of caregiver neuroticism would lead to a diminished response to the enhanced treatment and whether neuroticism affected the longitudinal course of caregiver depression regardless of intervention.

DESIGN AND METHODS

We analyzed data from the NYU Spouse-Caregiver Intervention Study, which randomly assigned caregivers either to an enhanced treatment group that received a comprehensive intervention with counseling, support, and consultation, or to a usual-care control group. The present study analyzed data from 320 caregivers, 160 in each group, who completed the NEO questionnaire. We used random-effects growth curve modeling to examine changes in depression in the first year after intake, examining possible effects of neuroticism on the course of caregiver depression and on response to intervention.

RESULTS

Caregivers high in neuroticism showed a worse longitudinal course of depression compared with those low in neuroticism in both the enhanced treatment and usual-care groups after we adjusted for baseline depression as a covariate. Caregivers showed benefits from the enhanced treatment compared with usual care, regardless of neuroticism score. However, caregivers low in neuroticism responded to treatment with declining levels of depression, whereas caregivers high in neuroticism maintained their baseline level of depression.

IMPLICATIONS

Caregiver neuroticism is a risk factor for increased caregiver depression over time. High neuroticism does not preclude successful caregiver intervention with a highly individualized intervention like ours, but expectations of outcome should be different than for caregivers low in neuroticism. Future studies should investigate the relationship between neuroticism and response to less individualized interventions and the impact of other personality characteristics on response to treatment.

Clinicians' predictions of patient response to psychotropic medications

Clinicians prescribe a medication when they assume that there is a reasonable probability of its success. There are many studies on the predictive value of social or clinical information, but these studies do not include the prognosis made by psychiatrists before treatment. These studies indicate that a small to moderate proportion of the total variance of outcome can be predicted from social or clinical information. It is peculiar that there are very few studies on the accuracy of psychiatrists’ “bets” about the effects of psychotropic drugs when they use the clinical characteristics of patients as predictors, considering the practical relevance of predicting the outcome of a psychiatric treatment. The absence of studies on the accuracy of clinicians’ bets or predictions in psychiatry is unfortunate.

Do early responders to psychotherapy maintain treatment gains?

This study examined early positive response to psychotherapy in a sample of 147 college student clients seeking therapy at a university counseling center. Early response was determined based on a score representing the difference between client-obtained symptom distress session scores and expected scores derived from a large actuarial study of typical treatment response. In the present study, early positive response to therapy was associated with fewer psychological symptoms at therapy termination and follow-up and maintenance of therapy gains. These results are discussed in relation to placebo effects and common factors and their primary importance in producing meaningful change. Future research directions are recommended that include the use of early response for exploring the contribution of client variables and theoretically derived interventions as they relate to the outcome of psychotherapy.

Psychological predictors of single and recurrent major depressive episodes

AIM

To examine for differential psychological risk factors in a nonclinical sample having single or recurrent episodes of major depression.

METHODS

A cohort of 164 subjects was assessed initially in 1978 in their last year of teacher training, and at five-yearly intervals in 1983, 1988 and 1993. Experience of episodes of DSM major depression and anxiety disorders from each wave were summed and three groups (nil, one, and two or more episodes of major depression) were derived. The cohort also completed a series of self-report measures including neuroticism, state and trait depression, self-esteem, dependency, childhood parental environment and social support.

RESULTS

The group with two or more episodes were distinctly more likely to have met lifetime criteria for an anxiety disorder and to have had multiple anxiety disorder diagnoses over their lifetime. Groups with one or more episodes reported higher mean scores for trait depression, neuroticism and maternal overprotection and lower mean scores for paternal care and self esteem at baseline in 1978, but these variables did not predict differences between groups with single and recurrent episodes. At 1993, those with two or more episodes differed from those with none and single episodes in reporting lower trait depression scores and decreased perception of satisfactory social support over time, suggesting a psychological scarring effect for those with repeated episodes.

Personality dimensions and depression: review and commentary

OBJECTIVES

The relationship between dimensionally assessed personality and the onset, features, and course of depressive illness will be critically examined and considered in relation to 4 hypothesized models: predisposition or vulnerability: pathoplasty: complication or scar: and spectrum or continuity.

METHOD

Studies that have used clinically depressed adult patients to explore the relationship between personality dimensions and depression will be reviewed.

RESULTS

Higher-order personality factors that have shown a significant and consistent association with major depressive illness include neuroticism, extraversion (negative relationship), and the factors of Cloninger's Tridimensional Personality Model. Neuroticism appears to be the most powerful predictor of depression. Lower-order factors showing a significant and consistent relationship with depressive illness include dependency, self-criticism, obsessionality, and perfectionism. The links between depression and dependency and self-criticism have the strongest empirical support.

CONCLUSIONS

Several personality dimensions are significantly associated with depressive illness, but the evidence that unequivocally demonstrates a true personality predisposition for depression is modest. Measures of personality may prove to be clinically useful for treatment selection.

Partial remission in depressive disorders

Although the concept of partial or incomplete remission from depression has been noted in the literature for many decades, it is only recently that a precise definition of partial remission has been formulated (1). This paper reviews publications relating to this concept, in terms of prevalence, clinical characteristics and implications for prognosis. There have been too few studies to allow conclusive evidence to be presented, but partial remission may affect one third of subjects treated for depression, and may increase the risk of further depressive relapse and adversely affect social and work performance. This paper highlights the need to increase awareness of this concept among clinicians so that residual symptoms may be aggressively treated, and also comments on the need for researchers to consider this important group in all treatment and outcome studies.