Epidemiology and costs of depressive disorder in Spain: the EPICO study

Cost-effectiveness of pharmacogenetic screening in the management of major depressive disorder in the Spanish Healthcare System

BACKGROUND

Major depressive disorder (MDD) represents a sizable economic burden in Spain. Pharmacogenetic (PGx) screening to guide the choice of antidepressant medication (ADM) in MDD patients yields higher response and remission rates, which could reduce both healthcare and indirect costs.

METHODS

We built a cost-effectiveness probabilistic Markov model with microsimulation using Tree Age Pro 2022, simulating a patient cohort from the SNHS starting ADM for MDD, and comparing PGx screening before starting ADM versus no screening (No PGx). We carried out a probabilistic sensitivity analysis using the Monte Carlo simulation with microsimulation, set for 1000 iterations and 1000 microsimulation trials, both from societal and healthcare provider perspectives, for a time horizon of 3 years.

RESULTS

From a societal perspective, the model estimated a mean cost of 3172.85€ and effectiveness of 2.64 quality-adjusted life years (QALYs) for the No PGx strategy, and a mean cost of 1687.02€ and effectiveness of 2.84 QALYs for the PGx strategy. The mean ICER was -7820.56 €/QALY. From a healthcare provider perspective (no indirect costs considered), the mean cost was 662.62€ for the No PGx strategy, and 446.60€ for the PGx strategy. The mean ICER was -1130.16 €/QALY.

LIMITATIONS

The heterogeneity of input data from the literature, the need for assumptions of homogeneous distribution of variables and events across population and time, and the inherent limitations of cost-effectiveness analysis should be considered. The model omits combined therapies (ADMs with mood stabilizers, antipsychotics, cognitive behavioral therapy…).

CONCLUSIONS

PGx screening in MDD prior to ADM start is a dominant strategy in the SNHS.

Clinical Predictors of Mood Disorders and Prevalence of Neuropsychiatric Symptoms in Patients with Systemic Lupus Erythematosus

Background/Objectives: We aimed to determine the prevalence and clinical correlations of mood disorders in a sample of systemic lupus erythematosus (SLE) patients. Hence, we hypothesized that the prevalence of mood disorders would be lower than reported in the literature and that patients would remain clinically stable and show less damage accrual despite low-dose corticosteroid prescription. Methods: In total, 92 SLE outpatients gave informed consent to participate in this cross-sectional study. Psychiatric and autoimmune clinical data were obtained, and a structured psychiatric interview was performed. The main clinical scales for the assessment of clinical symptomatology were included. To examine the potential relationships of presenting a mood disorder in SLE, clinical correlations and multivariate analyses were performed. Results: Mood disorders were the most prevalent disorder reported by SLE patients (16%), followed by adjustment disorders (5%). A significant proportion of patients presented psychosocial disturbances that did not meet the ICD-10 criteria for psychiatric diagnosis. According to the cut-off criterion for the Montgomery-Åsberg Depression Rating Scale (MADRS), up to 27% of the sample met the clinical criteria for depression. The multivariate analysis revealed a relationship between the presence of a mood disorder with total scores of the MADRS and the Young Mania Rating Scale (YMRS). Conclusions: The prevalence of mood disorders in patients with SLE was lower than previously reported. Although self-report clinical scales are useful for assessing clinical symptomatology, they should not be used in place of a comprehensive standardized interview conducted by a trained mental health specialist. Multidisciplinary teamwork is required for the early identification and therapeutic management of autoimmune patients with neuropsychiatric disorders.

Conceptualization of Depression among Medical Students and Its Differences during Medical Education

The definition of mental disorders has been traditionally a matter of discussion, and it has relevant implications in research and healthcare. Our aim was to explore the conceptualization medical students have of depression and to determine differences across academic years. The Maudsley Attitudes Questionnaire was adapted through a double translation, double back-translation and a preliminary validation, obtaining a Spanish edition. All students of the Faculty of Medicine of the University of Zaragoza and doctors who graduated from this University in 2020 were invited to answer the online questionnaire, and we received 222 answers (response rate: 15.2%). The results were compared by years and levels of education using an ANOVA. The social realist, behavioral, biological, cognitive and psychodynamic models were the most endorsed. The psychodynamic and nihilist models were less embraced by students in later educational years. These students also reported greater confidence in their understanding of depression and of its biological, cognitive and behavioral models. In conclusion, the conceptualization of depression among medical students is complex and multidimensional, and appears to be similar across different years of education. In later years, we found less support for the psychodynamic model, increased confidence in psychiatry and greater ease in handling the concepts of its leading models.

Effectiveness of Vortioxetine for the Treatment of Emotional Blunting in Patients with Major Depressive Disorder Experiencing Inadequate Response to SSRI/SNRI Monotherapy in Spain: Results from the COMPLETE Study

Background

The multinational, open-label COMPLETE study (NCT03835715) investigated the effectiveness of vortioxetine in alleviating emotional blunting in patients with major depressive disorder (MDD) experiencing inadequate response and emotional blunting while being treated with a selective serotonin reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI). This paper presents results for the subgroup of patients enrolled in Spain.

Methods

Patients with MDD (n = 67) experiencing partial response and emotional blunting during monotherapy with an SSRI or SNRI were switched to vortioxetine (10-20 mg/day) for 8 weeks. The primary study outcome was emotional blunting, assessed by the Oxford Depression Questionnaire (ODQ).

Results

After 8 weeks of vortioxetine, the mean (SE) change in ODQ total score from baseline was -26.0 (2.9) (P < 0.001). Respective changes in Montgomery-Åsberg Depression Rating Scale (MADRS), Motivation and Energy Inventory, Digit Symbol Substitution Test, and Sheehan Disability Scale (SDS) total scores were -14.9 (0.8), +34.2 (4.5), +6.3 (1.6), and ‒9.0 (1.3) (all P < 0.001 vs baseline). At week 8, 70.4% of patients no longer reported emotional blunting and 53.7% had achieved remission from their depressive symptoms (defined as a MADRS total score ≤10). Mediation analysis showed 77.1% of the change in SDS total score to be a direct effect of the improvement in ODQ total score after switching to vortioxetine. Adverse events were reported by 35 patients (52.2%), most commonly nausea (14 patients, 20.9%). At week 8, 33/54 patients (61.1%) were receiving vortioxetine 20 mg/day.

Conclusion

In this study investigating the effectiveness of vortioxetine in Spanish patients with MDD who experienced inadequate response and emotional blunting on SSRI/SNRI monotherapy, significant improvements in emotional blunting, core depressive symptoms (including anhedonia), sleep duration, motivation and energy, cognitive performance, and overall patient functioning were observed during the 8 weeks of treatment. Two-thirds of patients no longer reported emotional blunting and over half were in remission from their depressive symptoms at week 8.

Economic Evaluation of Videoconference Group Acceptance and Commitment Therapy and Behavioral Activation Therapy for Depression Versus Usual Care Among Adults With Chronic Low Back Pain Plus Comorbid Depressive Symptoms

Chronic pain and depression are frequently comorbid conditions associated with significant health care and social costs. This study examined the cost-utility and cost-effectiveness of videoconference-based group forms of Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD), as a complement to treatment-as-usual (TAU), for patients with chronic low back pain (CLBP) plus depressive symptoms, compared to TAU alone. A trial-based economic evaluation (n = 234) was conducted from a governmental and health care perspective with a time horizon of 12 months. Primary outcomes were the Brief Pain Inventory-Interference Scale (BPI-IS) and Quality Adjusted Life Year. Compared to TAU, ACT achieved a significant reduction in total costs (d = .47), and BATD achieved significant reductions in indirect (d = .61) and total costs (d = .63). Significant improvements in BPI-IS (d = .73 and d = .66, respectively) and Quality Adjusted Life Year scores (d = .46 and d = .28, respectively) were found in ACT and BATD compared to TAU. No significant differences in costs and outcomes were found between ACT and BATD. In the intention-to-treat analyses, from the governmental and health care perspective, no significant differences in cost reduction and incremental effects were identified in the comparison between ACT, BATD, and TAU. However, in the complete case analysis, significant incremental effects of ACT (∆BPI-IS = -1.57 and -1.39, respectively) and BATD (∆BPI-IS = -1.08 and -1.04, respectively) compared with TAU were observed. In the per-protocol analysis, only the significant incremental effects of ACT (∆BPI-IS = -1.68 and -1.43, respectively) compared to TAU were detected. In conclusion, ACT and BATD might be efficient options in the management of CLBP plus comorbid depression symptoms as compared to usual care. However, no clear difference was found in the comparison between the 2 active therapies regarding cost-effectiveness or cost-utility. PERSPECTIVE: The economic evaluation of psychological therapies for the management of complex conditions can be used in decision-making and resource allocation. This study provides evidence that ACT and BATD are more effective and involve a greater reduction in costs than usual care in the management of CLBP plus comorbid depressive symptoms. TRIAL NUMBER: NCT04140838.

Design of a Remote Multiparametric Tool to Assess Mental Well-Being and Distress in Young People (mHealth Methods in Mental Health Research Project): Protocol for an Observational Study

BACKGROUND

Mental health conditions have become a substantial cause of disability worldwide, resulting in economic burden and strain on the public health system. Incorporating cognitive and physiological biomarkers using noninvasive sensors combined with self-reported questionnaires can provide a more accurate characterization of the individual's well-being. Biomarkers such as heart rate variability or those extracted from the electrodermal activity signal are commonly considered as indices of autonomic nervous system functioning, providing objective indicators of stress response. A model combining a set of these biomarkers can constitute a comprehensive tool to remotely assess mental well-being and distress.

OBJECTIVE

This study aims to design and validate a remote multiparametric tool, including physiological and cognitive variables, to objectively assess mental well-being and distress.

METHODS

This ongoing observational study pursues to enroll 60 young participants (aged 18-34 years) in 3 groups, including participants with high mental well-being, participants with mild to moderate psychological distress, and participants diagnosed with depression or anxiety disorder. The inclusion and exclusion criteria are being evaluated through a web-based questionnaire, and for those with a mental health condition, the criteria are identified by psychologists. The assessment consists of collecting mental health self-reported measures and physiological data during a baseline state, the Stroop Color and Word Test as a stress-inducing stage, and a final recovery period. Several variables related to heart rate variability, pulse arrival time, breathing, electrodermal activity, and peripheral temperature are collected using medical and wearable devices. A second assessment is carried out after 1 month. The assessment tool will be developed using self-reported questionnaires assessing well-being (short version of Warwick-Edinburgh Mental Well-being Scale), anxiety (Generalized Anxiety Disorder-7), and depression (Patient Health Questionnaire-9) as the reference. We will perform correlation and principal component analysis to reduce the number of variables, followed by the calculation of multiple regression models. Test-retest reliability, known-group validity, and predictive validity will be assessed.

RESULTS

Participant recruitment is being carried out on a university campus and in mental health services. Recruitment commenced in October 2022 and is expected to be completed by June 2024. As of July 2023, we have recruited 41 participants. Most participants correspond to the group with mild to moderate psychological distress (n=20, 49%), followed by the high mental well-being group (n=13, 32%) and those diagnosed with a mental health condition (n=8, 20%). Data preprocessing is currently ongoing, and publication of the first results is expected by September 2024.

CONCLUSIONS

This study will establish an initial framework for a comprehensive mental health assessment tool, taking measurements from sophisticated devices, with the goal of progressing toward a remotely accessible and objectively measured approach that maintains an acceptable level of accuracy in clinical practice and epidemiological studies.

TRIAL REGISTRATION

OSF Registries N3GCH; https://doi.org/10.17605/OSF.IO/N3GCH.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51298.

Decoding and reconstructing disease relations between dry eye and depression: a multimodal investigation comprising meta-analysis, genetic pathways and Mendelian randomization

INTRODUCTION

The clinical presentations of dry eye disease (DED) and depression (DEP) often comanifest. However, the robustness and the mechanisms underlying this association were undetermined.

OBJECTIVES

To this end, we set up a three-segment study that employed multimodality results (meta-analysis, genome-wide association study [GWAS] and Mendelian randomization [MR]) to elucidate the association, common pathways and causality between DED and DEP.

METHODS

A meta-analysis comprising 26 case-control studies was first conducted to confirm the DED-DEP association. Next, we performed a linkage disequilibrium (LD)-adjusted GWAS and targeted phenotype association study (PheWAS) in East Asian TW Biobank (TWB) and European UK Biobank (UKB) populations. Single-nucleotide polymorphisms (SNPs) were further screened for molecular interactions and common pathways at the functional gene level. To further elucidate the activated pathways in DED and DEP, a systemic transcriptome review was conducted on RNA sequencing samples from the Gene Expression Omnibus. Finally, 48 MR experiments were implemented to examine the bidirectional causation between DED and DEP.

RESULTS

Our meta-analysis showed that DED patients are associated with an increased DEP prevalence (OR = 1.83), while DEP patients have a concurrent higher risk of DED (OR = 2.34). Notably, cross-disease GWAS analysis revealed that similar genetic architecture (rG = 0.19) and pleiotropic functional genes contributed to phenotypes in both diseases. Through protein-protein interaction and ontology convergence, we summarized the pleiotropic functional genes under the ontology of immune activation, which was further validated by a transcriptome systemic review. Importantly, the inverse variance-weighted (IVW)-MR experiments in both TWB and UKB populations (p value <0.001) supported the bidirectional exposure-outcome causation for DED-to-DEP and DEP-to-DED. Despite stringent LD-corrected instrumental variable re-selection, the bidirectional causation between DED and DEP remained.

CONCLUSION

With the multi-modal evidence combined, we consolidated the association and causation between DED and DEP.

Cost-effectiveness and cost-utility study of a psychoeducational group intervention for people with depression and physical comorbidity in primary care

OBJECTIVE

To evaluate the cost-effectiveness and cost-utility of a psychoeducational group intervention led by primary care (PC) nurses in relation to customary care to prevent the depression and improve quality of life in patients with physical comorbidity.

DESIGN

Economic evaluation based on data from randomized, multicenter clinical trial with blind response variables and a one-year follow-up, carried in the context of the PSICODEP study.

LOCATION

7 PC teams from Catalonia.

PARTICIPANTS

>50 year-old patients with depression and some physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma.

INTERVENTION

12 psychoeducational group sessions, 1 per week, led by 2 PC nurses with prior training.

MEASUREMENTS

Effectiveness: depression-free days (DFD) calculated from the BDI-II and quality-adjusted life years (QALYs) from the Euroqol-5D. Direct costs: PC visits, mental health, emergencies and hospitalizations, drugs. Indirect costs: days of temporary disability (TD). The incremental cost-effectiveness ratios (ICER), cost-effectiveness (ΔCost/ΔDLD) and cost-utility (ΔCost/ΔQALY) were estimated.

RESULTS

The study includes 380 patients (intervention group [IG] = 204; control group [CG] = 176). 81.6% women; mean age 68.4 (SD = 8.8). The IG had a higher mean cost of visits, less of hospitalizations and less TD than the CG. The difference in costs between the IG and the CG was -357.95€ (95% CI: -2026.96 to 1311.06) at one year of follow-up. There was a mean of 11.95 (95% CI: -15.98 to 39.88) more DFD in the IG than in the CG. QALYs were similar (difference -0.01, 95% CI -0.04 to 0.05). The ICERs were 29.95€/DLD and 35,795€/QALY.

CONCLUSIONS

Psychoeducational intervention is associated with an improvement in DFD, as well as a reduction in costs at 12 months, although not significantly. QALYs were very similar between groups.

Treating Treatment-resistant Depression with Esketamine Nasal Spray When All Therapeutic Options Have Been Exhausted: Clinical Experience from a Spanish Cohort of Expanded Use

Objective

: Treatment Resistant Depression (TRD) is commonly defined as the lack of response to two or more anti-depressants with different mechanisms of action. Up to 30% of patients diagnosed with major depressive disorder might be considered to present TRD. The objective of this study was to assess the effectiveness and tolerability of esketamine in patients diagnosed with TRD, who were referred to our program after exhausting all available treatments. A secondary objective consisted in researching the relationship between response and previous use of electroconvulsive therapy.

Methods

: A prospective, observational study was carried out in patients enrolled in the expanded use of esketamine in our center. They received esketamine prior to its marketing authorisation, for therapeutic purposes. Sixteen subjects were analyzed. Effectiveness was assessed with the Montgomery-Asberg depression rating scale (MADRS). Patients were followed up to 4 months after the administration.

Results

: Esketamine showed a rapid, robust effect in improving depressive symptoms, with no specific correlation between outcome and any demographic or clinical traits evaluated. No differences were found between patients that previously received Electroconvulsive Therapy, and those that didn't. 10 out of 16 patients responded (＞ 50% change in baseline MADRS scores), but only five achieved remission (＜ 12 points in the global MADRS score). We provide some recommendations, based on clinical experience, to improve tolerability and adherence, and to manage adverse effects.

Conclusion

: Results suggest that esketamine is a safe, effective and rapid-acting option for TRD. More studies are needed to properly assess predictors of response outcome.

Using ecological momentary assessment and machine learning techniques to predict depressive symptoms in emerging adults

The objective of this study was to predict the level of depressive symptoms in emerging adults by analyzing sociodemographic variables, affect, and emotion regulation strategies. Participants were 33 emerging adults (M = 24.43; SD = 2.80; 56.3 % women). They were asked to assess their current emotional state (positive or negative affect), recent events that may relate to that state, and emotion regulation strategies through ecological momentary assessment. Participants were prompted randomly by an app 6 times per day between 10 am and 10 pm for a seven-day period. They answered 1233 of the 2058 surveys (beeps), collectively. The analysis of observations, using Machine Learning (ML) techniques, showed that the Random Forest algorithm yields significantly better predictions than other models. The algorithm used 13 out of the 36 variables adopted in the study. Furthermore, the study revealed that age, emotion of worried and a specific emotion regulation strategy related to social exchange were the most accurate predictors of severe depressive symptoms. By carefully selecting predictors and utilizing appropriate sorting techniques, these findings may provide valuable supplementary information to traditional diagnostic methods and psychological assessments.

Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

Utility of PHQ-2, PHQ-8 and PHQ-9 for detecting major depression in primary health care: a validation study in Spain

BACKGROUND

Primary health care (PHC) professionals may play a crucial role in improving early diagnosis of depressive disorders. However, only 50% of cases are detected in PHC. The most widely used screening instrument for major depression is the Patient Health Questionnaire (PHQ), including the two-, eight- and nine-item versions. Surprisingly, there is neither enough evidence about the validity of PHQ in PHC patients in Spain nor indications about how to interpret the total scores. This study aimed to gather validity evidence to support the use of the three PHQ versions to screen for major depression in PHC in Spain. Additionally, the present study provided information for helping professionals to choose the best PHQ version according to the context.

METHODS

The sample was composed of 2579 participants from 22 Spanish PHC centers participating in the EIRA-3 study. The reliability and validity of the three PHQ versions for Spanish PHC patients were assessed based on responses to the questionnaire.

RESULTS

The PHQ-8 and PHQ-9 showed high internal consistency. The results obtained confirm the theoretically expected relationship between PHQ results and anxiety, social support and health-related QoL. A single-factor solution was confirmed. Regarding to the level of agreement with the CIDI interview (used as the criterion), our results indicate that the PHQ has a good discrimination power. The optimal cut-off values were: ⩾2 for PHQ-2, ⩾7 for PHQ-8 and ⩾8 for PHQ-9.

CONCLUSIONS

PHQ is a good and valuable tool for detecting major depression in PHC patients in Spain.

Agricultural activities and risk of treatment for depressive disorders among the entire French agricultural workforce: the TRACTOR project, a nationwide retrospective cohort study

Background

Although depression is a major issue among farming population, to date, there have been few studies on specific agricultural activities. We aimed to investigate whether, among the entire French farm manager (FM) workforce, certain agricultural activities are more strongly associated with depression than others.

Methods

This nationwide retrospective cohort study used data from an administrative health database available to the TRACTOR project. This database pertains to the entire French agricultural workforce (overseas workers not included). Data were analyzed from January 2021 to December 2022. All FMs that worked at least once over the period 2002-2016 were included. The outcome measure was the association between 26 agricultural activities and the risk of depression measured as hazard ratios (HRs) after adjusting for age, sex, and pre-existing medical comorbidities. The time to first depression insurance declaration, or first antidepressant prescription claim was used as the underlying timescale. For each activity, the reference/control group included all FMs that never performed the considered activity between 2002 and 2016, while the exposed group included FMs that performed the considered activity at least once from 2002 to 2016. Four sensitivity analyses were conducted to test hypotheses, and to address potential sources of bias.

Findings

There were 84,507 (7.76%; 28.2 cases per 1000 person-years) depression cases among 1,088,561 FMs (mean age 46.6 [SD 14.1]). Compared to other activities, dairy farming (HR = 1.37, 95% confidence interval: 1.32-1.42), cow farming (HR = 1.53 [1.47-1.59]), poultry and rabbit farming (HR = 1.37 [1.27-1.50]), and mixed farming (HR = 1.30 [1.24-1.36]) were more strongly associated with depression. Sex differences were observed, with most of the time, risks higher for females than for males.

Interpretation

Agricultural activities at risk of depression among the entire French agricultural workforce were identified. These findings do represent a crucial first step on the road to implement effective preventive measures against depression to determine where additional resources should be allocated to screen for depression, along with intervention.

Funding

MIAI@Grenoble Alpes, and Mutualité Sociale Agricole.

Meaning in life as a protective factor against depression

The main objective of this study was to analyze the mediating role that meaning in life has between emotion dysregulation and depressive symptomatology in Spanish university students. Five hundred and sixty-six Spanish university students participated in the study. All of them completed the Difficulties in Emotion Regulation Scale (DERS), the Patient Health Questionnaire (PHQ-9) and the Purpose in Life Test (PIL-10). A mediation model was performed to test the hypothesis that meaning in life mediates the effect of emotional dysregulation on depressive symptomatology in college students. The results show a positive, moderate, and statistically significant correlation between depression and emotional dysregulation. In addition, a negative, moderate, and statistically significant correlation was found between depression and meaning in life, and a negative, small, and statistically significant correlation between emotional dysregulation and meaning in life. Finally, the results of the mediation model evidence the role of meaning in life in different emotional dysregulation strategies and depressive symptomatology. These findings suggest the importance of incorporating the meaning in life variable in the development and implementation of prevention and treatment programs for psychological disorders.

Calprotectin, Biomarker of Depression in Patients with Inflammatory Bowel Disease?

Background and Objectives: Calprotectin is a marker for intestinal inflammation. Recent research suggests a link between inflammation and depression. This study assessed the association between the levels of calprotectin in patients from South-Eastern Europe and the severity of depression, anxiety, and quality of life. Materials and Methods: This cross-sectional study included 30 confirmed patients with Crohn's disease (CD) and ulcerative colitis (UC) who were assessed using clinical interviews for determining the severities of mental disorders (i.e., depression severity-PHQ-9, anxiety-GAD-7) and the quality of life (EQ-5D). Stool samples were collected from all participants for measuring their levels of calprotectin. Results: The level of calprotectin is correlated with PHQ-9 (ρ = 0.416, p = 0.022) and EQ-5D (ρ = -0.304, p = 0.033) but not with GAD 7 (ρ = 0.059, p = 0.379). Calprotectin levels in patients with mild, moderate, and moderately severe depression were significantly higher than in patients with minimal depression (198 µg/g vs. 66,9 µg/g, p = 0.04). Calprotectin level was corelated with the following depressive symptoms: autolytic ideation (ρ = 0.557, p = 0.001), fatigue (ρ = 0.514, p = 0.002), slow movement (ρ = 0.490, p = 0.003), and sleep disorders (ρ = 0.403, p = 0.014). Calprotectin was an independent predictor of depression with an odds ratio of 1.01 (95%: 1.002-1.03, p < 0.01). An ROC analysis showed that a level of calprotectin of 131 µg/g or higher has a sensitivity of 82%, a specificity of 61%, and an accuracy of 70% for predicting depression. In this study, no significant correlations were found between calprotectin level and anxiety. Conclusions: Calprotectin levels are associated with the severity of depression, and checking for a calprotectin level of 131 µg/g or higher may be a potential accessible screening test for depression in patients with inflammatory bowel disease.

Depression and suicidality severity among TRD patients after 1-year under standard of care: Findings from the TRAL study, a multicenter, multinational, observational study in Latin America

INTRODUCTION

Treatment resistant depression (TRD) is one of the most pressing issues in mental healthcare in LatAm. However, clinical data and outcomes of standard of care (SOC) are scarce. The present study reported on the Treatment-Resistant Depression in America Latina (TRAL) project 1-year follow-up of patients under SOC assessing clinical presentation and outcomes.

MATERIALS AND METHODS

420 patients with clinical diagnoses of TRD from Argentina, Brazil, Colombia and Mexico were included in a 1-year follow-up to assess clinical outcomes of depression (MADRS) and suicidality (C-SSRS), as well as evolution of clinical symptoms of depression. Patients were assessed every 3 months and longitudinal comparison was performed based on change from baseline to each visit and end of study (12 months). Socio demographic characterization was also performed.

RESULTS

Most patients were female (80.9%), married (42.5%) or single (34.4%), with at least 10 years of formal education (71%). MDD diagnosis was set at 37.29 (SD=14.00) years, and MDD duration was 11.11 years (SD=10.34). After 1-year of SOC, 79.1% of the patients were still symptomatic, and 40% of the patients displayed moderate/severe depression. Only 44.1% of the patients achieved a response (≥50% improvement in MADRS), and 60% of the sample failed to achieve remission. Suicidal ideation was reported by more than half of the patients at the end of study.

CONCLUSIONS

Depression and suicidality symptoms after a 1-year of SOC is of great concern. Better therapeutic options are needed to tackle this debilitating and burdensome disease.

An urban green space intervention with benefits for mental health: A health impact assessment of the Barcelona "Eixos Verds" Plan

BACKGROUND

Mental health disorders account for over 30% of the global burden of disease. There is a positive association between green space exposure and better mental health, and therefore urban greening can be an effective public health tool. Barcelona is a compact city with one of the highest population and traffic densities in Europe, with limited green spaces. Under the umbrella of the Superblock model, the Barcelona City council is implementing the Eixos Verds Plan for extensive street greening. We estimated the potential mental health benefits of this plan.

METHODS

We performed a quantitative health impact assessment at the Barcelona grid-cell level (n = 1,096). We compared the baseline green space situation (2015) with the proposed plan and translated the increase in green space into a) percentage of green area (%GA) and b) NDVI. We combined exposure data with Barcelona-specific mental health risk estimates, adult population (n = 1,235,375), and mental health data, and calculated preventable cases.

FINDINGS

Under the Eixos Verds Plan, we estimated an average increase of 5·67 %GA (range: 0·00% - 15·77%) and 0·059 NDVI (range: 0·000 - 0·312). We estimated that with the Eixos Verds Plan implementation, 31,353 (95%CI: 18,126-42,882) cases of self-perceived poor mental health (14·03% of total), 16,800 (95%CI: 6828-25,700) visits to mental health specialists (13·37% of total), 13,375 (95%CI: 6107-19,184) cases of antidepressant use (13·37% of total), and 9476 (95%CI: 802-16,391) cases of tranquilliser/ sedative use (8·11% of total) could be prevented annually, along corresponding to over 45 M € annual savings in mental health costs annually.

INTERPRETATION

Our results highlight the importance of urban greening as a public health tool to improve mental health in cities. Similar results for green interventions in other cities could be expected.

Depression in Central and Eastern Europe: How Much It Costs? Cost of Depression in Romania

OBJECTIVE

The present study aims to estimate the public cost of depression in Romania during a seven-year time span to complement existing papers with data from Central and Eastern Europe and to identify and propose measures that allow efficient use of funds.

METHODS

We used data collected from the National Health Insurance System to analyze the main components of the cost.

FINDINGS

Indirect costs exceed direct costs. Within the direct costs, hospitalization and medicines still have an important share but are decreasing due to the intervention of outpatient services such as psychiatrists and psychotherapists.

CONCLUSION

Since the goal is mental health, it is necessary to act early and quickly to decrease the burden in the long run. Annually, the mean direct cost of depression per patient is EUR 143 (part of it is represented by hospitalization, i.e., EUR 67, and psychotherapy, i.e., EUR 5), the mean cost of sick leaves per patient is EUR 273, and the total cost per patient is EUR 5553. Indirect costs (cost of disability and lost productive years) represent 97.17% of the total cost. An integrated approach to early diagnosis, effective treatment, monitoring, and prevention as well as included economic and social programs are needed to optimize indirect costs.

Enhancing Internet-based psychotherapy for adults with emotional disorders using ecological momentary assessments and interventions: Study protocol of a feasibility trial with "My EMI, Emotional Well-being" app

Introduction

Emotional disorders are the most frequent mental health problems globally. To ensure the dissemination of psychological treatments for these conditions, novel forms of delivery (e.g., Internet or mobile apps) and more scalable forms of psychotherapy (e.g., transdiagnostic interventions) have become increasingly popular. Research, however, shows that a significant number of patients, around 40 % according to some studies, do not respond to the interventions as expected (i.e., not-on-track patients). Ecological momentary assessments (EMAs) and ecological momentary interventions (EMIs) could simplify tailoring treatments to the patients' progress and rapidly respond to undesired outcomes during psychotherapy. Therefore, these would facilitate measurement-based care with little therapist involvement. This study aims to explore the feasibility of an app-based system called My EMI, Emotional Well-being for people with emotional disorders. According to daily EMAs, the app will provide personalized EMIs while participants receive a self-applied online transdiagnostic treatment. The app will be used as an add-tool to the online intervention to address emotion dysregulation, foster adherence, and reinforce contents. The current study describes the study protocol for this trial.

Method and analysis

A single-group, open trial design will be used. Participants will be 30 adults suffering from emotional disorders. Primary outcomes will be app usability, acceptability, and response rates. Secondary outcomes will be either evaluated in Qualtrics at pre-treatment, post-treatment, and 3-month follow-up (depression and anxiety severity, and transdiagnostic dimensions of emotional disorders) or daily throughout the study with the app (EMAs of mood and five transdiagnostic mechanisms of therapeutic change). EMIs will consist of brief, evidence-based transdiagnostic CBT digital content (images, infographics, or videos) delivered just-in-time. Only if problems persist, short phone calls or episodic videocalls will be conducted. The Ethics Committee of the Jaume I University approved the study and all its procedures (CD/111/2021) in December 2021.

Discussion

Identifying personalized and scalable interventions is paramount to improve mental health care, especially its accessibility, and to reduce the psychological distress of people with mental health problems. Feasibility data of the app (EMA and EMI system) supported by a self-applied online transdiagnostic intervention will be important to explore whether this modern approach is a real option to move forward personalized psychological interventions for persons with emotional disorders.

Trial registration

ClinicalTrials.gov Identifier: NCT05109780. Registered 05 November 2021, https://clinicaltrials.gov/ct2/show/NCT05109780.

Current Opinions about the Use of Duloxetine: Results from a Survey Aimed at Psychiatrists

Major depressive disorder (MDD) is a complex psychiatric disorder that, presented alone or with other comorbidities, requires different adjustments of antidepressant treatments. Some investigations have demonstrated that psychoactive drugs, such as serotonin and norepinephrine reuptake inhibitors (SNRIs), can exert more effective and faster antidepressant effects than other common medications used, such as serotonin selective reuptake inhibitors (SSRIs), although these differences are still controversial. During the last five years, the SNRI duloxetine has shown favorable results in clinical practice for the treatment of MDD, anxiety, and fibromyalgia. Through an online self-completed survey, in the present article, we collected information from 163 psychiatrists regarding the use of duloxetine and its comparison with other psychiatric drugs, concerning psychiatrists' knowledge and experience, as well as patients' preferences, symptoms, and well-being. We discussed and contrasted physicians' reports and the scientific literature, finding satisfactory concordances, and finally concluded that there is agreement regarding the use of duloxetine, not only due to its tolerability and effectiveness but also due to the wide variety of situations in which it can be used (e.g., somatic symptoms in fibromyalgia, diabetes) as it relieves neuropathic pain as well.

Mental Adjustment, Functional Status, and Depression in Advanced Cancer Patients

Depressive symptoms are common in individuals with advanced cancer.

OBJECTIVES

This study sought to analyze the relationship between physical and functional status and depressive symptoms, and to assess the role of mental adjustment across these variables in people with advanced cancer.

METHODS

A prospective, cross-sectional design was adopted. Data were collected from 748 participants with advanced cancer at 15 tertiary hospitals in Spain. Participants completed self-report measures: Brief Symptom Inventory (BSI), Mini-Mental Adjustment to Cancer (Mini-MAC) scale, and the European Organization for Research and Treatment of Cancer (EORTC) questionnaire.

RESULTS

Depression was present in 44.3% of the participants and was more common among women, patients <65 years old, non-partnered, and those with recurrent cancer. Results revealed a negative correlation with functional status, and functional status was negatively associated with depressive symptoms. Mental adjustment affected functional status and depression. Patients having a positive attitude displayed fewer depressive symptoms, while the presence of negative attitudes increased depressive symptoms in this population.

CONCLUSIONS

Functional status and mental adjustment are key factors in the presence of depressive symptoms among people with advanced cancer. Assessment of functional status and mental adjustment should be considered when planning treatment and rehabilitation in this population.

Neuroinflammation related to the blood-brain barrier and sphingosine-1-phosphate in a pre-clinical model of periodontal diseases and depression in rats

AIM

To explore the potential mechanisms of neuroinflammation (microglia, blood-brain barrier [BBB] permeability, and the sphingosine-1-phosphate [S1P] pathways) resulting from the association between periodontitis and depression in rats.

MATERIALS AND METHODS

This pre-clinical in vivo experimental study used Wistar rats, in which experimental periodontitis (P) was induced by using oral gavages with Porphyromonas gingivalis and Fusobacterium nucleatum. Then, a chronic mild stress (CMS) model was implemented to induce a depressive-like behaviour, resulting in four groups: P with CMS (P+CMS+), P without CMS (P+CMS-), CMS without P (P-CMS+), and control (P-CMS-). After harvesting brain samples, protein/mRNA expression analyses and fluorescence immunohistochemistry were performed in the frontal cortex (FC). Results were analysed by ANOVA.

RESULTS

CMS exposure increased the number of microglia (an indicator of neuroinflammation) in the FC. In the combined model (P+CMS+), there was a decrease in the expression of tight junction proteins (zonula occludens-1 [ZO-1], occludin) and an increase in intercellular and vascular cell adhesion molecules (ICAM-1, VCAM-1) and matrix metalloproteinase 9 (MMP9), suggesting a more severe disruption of the BBB. The enzymes and receptors of S1P were also differentially regulated.

CONCLUSIONS

Microglia, BBB permeability, and S1P pathways could be relevant mechanisms explaining the association between periodontitis and depression.

A GBD 2019 study of health and Sustainable Development Goal gains and forecasts to 2030 in Spain

This study aimed to report mortality, risk factors, and burden of diseases in Spain. The Global Burden of Disease, Injuries, and Risk Factors 2019 estimates the burden due to 369 diseases, injuries, and impairments and 87 risk factors and risk factor combinations. Here, we detail the updated Spain 1990-2019 burden of disease estimates and project certain metrics up to 2030. In 2019, leading causes of death were ischaemic heart disease, stroke, chronic obstructive pulmonary disease, Alzheimer's disease, and lung cancer. Main causes of disability adjusted life years (DALYs) were ischaemic heart disease, diabetes, lung cancer, low back pain, and stroke. Leading DALYs risk factors included smoking, high body mass index, and high fasting plasma glucose. Spain scored 74/100 among all health-related Sustainable Development Goals (SDGs) indicators, ranking 20 of 195 countries and territories. We forecasted that by 2030, Spain would outpace Japan, the United States, and the European Union. Behavioural risk factors, such as smoking and poor diet, and environmental factors added a significant burden to the Spanish population's health in 2019. Monitoring these trends, particularly in light of COVID-19, is essential to prioritise interventions that will reduce the future burden of disease to meet population health and SDG commitments.

The relationship between the Mediterranean diet and Axis I disorders: A systematic review of observational studies

Axis I disorders are one of the major health burdens worldwide. Evidence suggests that Mediterranean diet has key biological factors associated with reducing the progression of these disorders. This systematic review aimed to clarify the relationship between Mediterranean diet and Axis I disorders. PubMed and Scopus databases were searched from January 2016 up to June 2021. Those observational studies in English language that assessed the relationship between Mediterranean diet and Axis I disorders (such as depression, anxiety, eating disorders, schizophrenia, etc.) were included in this review. The Newcastle-Ottawa Scale was used to evaluate the quality of studies. Thirty-six studies (15 cohorts, 19 cross-sectional, and 2 case-control) met the inclusion criteria. The results revealed that more than two-thirds of the studies (25 studies, 69.44%) had significant protective relationship between receiving Mediterranean diet and reducing the symptoms or incidence of Axis I disorders. Most studies were performed on depression (29 studies measured depression at least as one of the Axis I disorders), of which 72.41% reported an inverse relationship. There were also 9 studies on anxiety (studies that measured anxiety at least as one of the Axis I disorders), that 77.77% of them observed protective association. Moreover, majority of the studies (25 studies, 69.44%) had high quality, of which 76% found an inverse relationship. In conclusion, it seems that the Mediterranean diet can reduce the symptoms or the occurrence of Axis I disorders (especially depression and anxiety). However, more extensive review studies, particularly with interventional designs, are necessary to prove the result.

A Cross-Sectional Study on the Associations between Physical Activity Level, Depression, and Anxiety in Smokers and Ex-Smokers

Introduction: depression and anxiety is one of the most relevant public health problems. The link between smoking and depression has been demonstrated. Regular physical activity (PA) could act as a protector against mental health diseases. Objectives: (1) to explore the prevalence of depression and anxiety in relation to sex and to the condition of smoker and ex-smoker, (2) to study the differences in prevalence proportions according to the frequency and level of PA, and (3) to calculate the probability of presenting depression or anxiety according to the frequency and level of PA. Methods: a cross-sectional study was conducted, based on data extracted from the 2014 and 2020 Spanish European Health Survey and the 2017 Spanish National Health Survey. The sample included 9524, 7813, and 9079 participants, respectively. Descriptive analysis was performed (comparisons using a Chi-square test and z-test for independent proportions). Probability odds ratios of anxiety and depression were calculated according to PA. Results: women had a higher prevalence of depression and anxiety than men (p < 0.001−0.003). Higher levels of prevalence were observed in inactive people versus very active or active people (p < 0.001). Inactive people had a higher risk of depression and anxiety compared to very active people. Conclusion: inactive smokers and ex-smokers had higher levels of prevalence of depression and anxiety than active and very active people. Physical inactivity could increase the risk of suffering these mental disorders in this population. This could affect women more than men.

Long-term cost-effectiveness of group unified protocol in the Spanish public mental health system

The limited material and human resources available in the Spanish public mental health system, combined with the high prevalence of emotional disorders nowadays, makes it necessary to search for and implement other more cost-effective formats. The versatility of the Unified Protocol (UP) for the transdiagnostic treatment of emotional disorders allows its application in group format, which could be a cost-effective solution for the system. The aim of the present study is to investigate the cost-effectiveness of the UP applied in group format in specialized care units compared to the Treatment as usual (TAU) in the Spanish public mental health system over a 15-month time period. The sample of this study consisted of 188 patients, diagnosed with an emotional disorder, randomized to the UP condition in group format or to the TAU condition in individual format. The findings of this study have shown the same beneficial results for the participants with symptoms of anxiety and depression in both conditions and greater improvements in quality of life in the UP condition. Regarding cost-effectiveness results, at the 15-month follow-up, participants in the UP condition received a greater number of sessions, with a lower total economic cost compared to the TAU condition. Finally, reductions in the number of participants using antidepressants and a reduction in medication burden were found in the UP condition over time. The results of this study show that UP applied in a group format can be a cost-effectiveness solution for the Spanish public mental health system. Trial registration number: NCT03064477 (March 10, 2017).

The economic burden of pulmonary arterial hypertension in Spain

Background

Pulmonary Arterial Hypertension (PAH) is a rare, debilitating, and potentially fatal disease. This study aims to quantify the economic burden of PAH in Spain.

Methods

The study was conducted from a societal perspective, including direct and indirect costs associated with incident and prevalent patients. Average annual costs per patient were estimated by multiplying the number of resources consumed by their unit cost, differentiating the functional class (FC) of the patient. Total annual costs per FC were also calculated, taking the 2020 prevalence and incidence ranges into account. An expert committee validated the information on resource consumption and provided primary information on pharmacological consumption. Unit costs were estimated using official tariffs and salaries in Spain. A deterministic sensitivity analysis was conducted to test the uncertainty of the model.

Results

The average annual total cost was estimated at €98,839 per prevalent patient (FC I-II: €65,233; FC III: €103,736; FC IV: €208,821), being €42,110 for incident patients (FC I-II: €25,666; FC III: €44,667; FC IV: €95,188). The total annual cost of PAH in Spain, taking into account a prevalence between 16.0 and 25.9 cases per million adult inhabitants (FC I-II 31.8%; FC III 61.3%; FC IV 6.9%) and an incidence of 3.7, was estimated at €67,891,405 to €106,131,626, depending on the prevalence considered. Direct healthcare costs accounted for 64% of the total cost, followed by indirect costs (24%), and direct non-healthcare costs (12%). The total costs associated with patients in FC I-II ranged between €14,161,651 and €22,193,954, while for patients in FC III costs ranged between €43,763,019 and €68,391,651, and for patients in FC IV between €9,966,735 and €15,546,021. In global terms, patients with the worst functional status (FC IV) account for only 6.9% of the adults suffering from PAH in Spain, but are responsible for 14.7% of the total costs.

Conclusions

PAH places a considerable economic burden on patients and their families, the healthcare system, and society as a whole. Efforts must be made to improve the health and management of these patients since the early stages of the disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01906-2.

Immunomodulatory Role of CB2 Receptors in Emotional and Cognitive Disorders

Emotional behavior, memory, and learning have been associated with alterations in the immune system in neuropsychiatric and neurodegenerative diseases. In recent years, several studies pointed out the involvement of the cannabinoid receptor 2 (CB2r) in the immune system and the regulation of inflammation. This receptor is widely distributed in different tissues and organs with higher expression in spleen and immune system cells. However, CB2r has also been detected in several brain areas and different brain cell types, such as neurons and glia. These findings suggest that CB2r may closely relate the immune system and the brain circuits regulating inflammation, mood, and cognitive functions. Therefore, we review the studies that may help elucidate the molecular bases of CB2r in regulating inflammation in different brain cells and its role in the pathophysiology of psychiatric and neurodegenerative disorders.

Economic impact of treatment-resistant depression: A retrospective observational study

BACKGROUND

To determine the incidence of Treatment-Resistant Depression (TRD) in Spain and to estimate its economic burden, using real world data.

METHODS

A retrospective, observational-study was carried out using data from the BIG-PAC database®. Patients aged ≥18 years with a diagnosis of major depressive-disorder (MDD) who initiated a new antidepressant treatment in 2015-2017 were included. The patients were classified as TRD and non-TRD. Patients were classified as TRD if they had, during the first year of antidepressant treatment: a) failure with ≥2 antidepressants including the prescription of ≥3 antidepressants (N06A) or ≥2 antidepressant and ≥1 antipsychotic (N05A; including lithium) b) antidepressants administered for ≥ 4 weeks each, and c) the time between the end of one treatment and the initiation of the next was ≤ 90 days. Inherent limitations of data collection from databases should also be considered in this analysis (e.g., lack of information about adherence to treatment). Follow-up period: 18 months. The incidence rate was calculated as the number of TRD patients per 1,000 persons-year divided by the population attended.

OUTCOMES

direct healthcare and indirect costs. Two sensitivity analyses were performed varying the index date and the period used to define TRD patients (6 vs.12 months).

RESULTS

21,630 patients with MDD aged ≥ 18 years (mean age: 53.2 years; female: 67.2%) were analyzed, of whom 3,559 met TRD criteria, yielding a 3-year cumulative incidence of 16.5% (95%CI: 16%-17%) among MDD patients. The annual population incidence rate of TRD in 2015-2017, was 0.59, 1.02 and 1.18/1,000 person-years, respectively (mean: 0.93/1,000 person-year). Overall, mean total costs per MDD patient were €4,147.9, being higher for TRD than for non-TRD patients (€6,096 vs. €3,846; p<0.001): a) direct costs (€1,341 vs. €624; p<0.001), b) lost productivity (€1,274 vs. €821; p<0.001) and c) permanent disability (€3,481 vs. €2,401; p<0.001, adjusted). Sensitivity analyses showed no differences with the reported results.

CONCLUSIONS

The population based TRD incidence in Spain was similar to recent data from other European countries. TRD is associated with greater resource use and higher costs compared with non-TRD patients.