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Bhachech H, Nath K, Sidana R, Shah N, Nagpal R, Sathianathan R, Kakkad A, Korukonda K. Personalized Approach in the Management of Difficult-to-Treat and Treatment-Resistant Depression With Second-Generation Antipsychotics: A Delphi Statement. Cureus 2024; 16:e52878. [PMID: 38406088 PMCID: PMC10890970 DOI: 10.7759/cureus.52878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
Background Major depressive disorder (MDD) has many facets including mixed or atypical depression that requires personalized care to improve treatment-related outcomes. Second-generation antipsychotics (SGAs) offer complementary mechanisms for clinical roles in difficult-to-treat depression and treatment-resistant depression cases. Aim/objective To further delineate a consensus on the clinical positioning of SGAs for MDD, mixed, or atypical depression, a Knowledge Attitude Perception (KAP)-mediated Delphi Statement was planned. Material/methods A literature review for the definition, diagnosis, and management of MDD, mixed, and atypical depression as treatment-resistant depression (TRD) or difficult-to-treat depression (DTD) was conducted by a steering committee of academic and clinical experts (n=6) while developing a validated KAP questionnaire. Scientific statements as clinical recommendations were evolved using the Delphi methodology before building a clinical expert consensus with an online survey (n=24). Results Twenty-four psychiatrists highlighted DTD to offer a multidimensional approach to assess treatment strategies involving selective serotonin reuptake inhibitors (SSRIs) or SGAs, while ensuring symptom, functional, and quality of life (QoL) domain improvement for improved outcomes and remission rates. MDD cases with anxiety, anhedonia, comorbidities, and risk traits require personalized care with early induction of SGAs for severe cases or symptom persisters with functional impairment. Early augmentation with SGAs including aripiprazole or cariprazine can provide a favorable risk-benefit profile for clinical cases of MDD with or without the antecedent of mixed depression or personality disorder. Conclusion The literature review and KAP responses emphasize the importance of early identification for personalized care strategies with SGAs for DTD. Large-scale real-world evidence needs to evolve with due recognition of different phenotypes as TRD or DTD with partial or functional impairment to understand the impact of appropriate treatment pathways with SGAs.
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Affiliation(s)
| | - Kamal Nath
- Department of Psychiatry, Silchar Medical College and Hospital, Silchar, IND
| | - Roop Sidana
- Department of Psychiatry, Tekchand Sidana Memorial Psychiatric Hospital and Deaddiction Centre, Sriganganagar, IND
| | - Nilesh Shah
- Department of Psychiatry, Lokmanya Tilak Medical College, Sion, Mumbai, IND
| | - Rajesh Nagpal
- Department of Psychiatry, Manobal Clinic, New Delhi, IND
| | - R Sathianathan
- Department of Psychiatry, Madras Memory Clinic, Chennai, IND
| | - Ashutosh Kakkad
- Medical Services, Torrent Pharmaceuticals Limited, Ahmedabad, IND
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2
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Codeluppi SA, Xu M, Bansal Y, Lepack AE, Duric V, Chow M, Muir J, Bagot RC, Licznerski P, Wilber SL, Sanacora G, Sibille E, Duman RS, Pittenger C, Banasr M. Prefrontal cortex astroglia modulate anhedonia-like behavior. Mol Psychiatry 2023; 28:4632-4641. [PMID: 37696873 PMCID: PMC10914619 DOI: 10.1038/s41380-023-02246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/17/2023] [Accepted: 08/29/2023] [Indexed: 09/13/2023]
Abstract
Reductions of astroglia expressing glial fibrillary acidic protein (GFAP) are consistently found in the prefrontal cortex (PFC) of patients with depression and in rodent chronic stress models. Here, we examine the consequences of PFC GFAP+ cell depletion and cell activity enhancement on depressive-like behaviors in rodents. Using viral expression of diphtheria toxin receptor in PFC GFAP+ cells, which allows experimental depletion of these cells following diphtheria toxin administration, we demonstrated that PFC GFAP+ cell depletion induced anhedonia-like behavior within 2 days and lasting up to 8 days, but no anxiety-like deficits. Conversely, activating PFC GFAP+ cell activity for 3 weeks using designer receptor exclusively activated by designer drugs (DREADDs) reversed chronic restraint stress-induced anhedonia-like deficits, but not anxiety-like deficits. Our results highlight a critical role of cortical astroglia in the development of anhedonia and further support the idea of targeting astroglia for the treatment of depression.
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Affiliation(s)
- S A Codeluppi
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - M Xu
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Y Bansal
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - A E Lepack
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - V Duric
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Department of Physiology and Pharmacology, Des Moines University, West Des Moines, IA, USA
| | - M Chow
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - J Muir
- Integrated Program in Neuroscience, McGill University, Montréal, QC, Canada
| | - R C Bagot
- Department of Psychology, McGill University, Montreal, QC, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, QC, Canada
| | - P Licznerski
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Department of Internal Medicine, Section of Endocrinology, Yale University, New Haven, CT, USA
| | - S L Wilber
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - G Sanacora
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - E Sibille
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - R S Duman
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - C Pittenger
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - M Banasr
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, Yale University, New Haven, CT, USA.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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3
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McIntyre RS, Alsuwaidan M, Baune BT, Berk M, Demyttenaere K, Goldberg JF, Gorwood P, Ho R, Kasper S, Kennedy SH, Ly-Uson J, Mansur RB, McAllister-Williams RH, Murrough JW, Nemeroff CB, Nierenberg AA, Rosenblat JD, Sanacora G, Schatzberg AF, Shelton R, Stahl SM, Trivedi MH, Vieta E, Vinberg M, Williams N, Young AH, Maj M. Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions. World Psychiatry 2023; 22:394-412. [PMID: 37713549 PMCID: PMC10503923 DOI: 10.1002/wps.21120] [Citation(s) in RCA: 86] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
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.
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Affiliation(s)
- Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Mohammad Alsuwaidan
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Bernhard T Baune
- Department of Psychiatry, University of Münster, Münster, Germany
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Michael Berk
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
- Deakin University IMPACT Institute, Geelong, VIC, Australia
| | - Koen Demyttenaere
- Department of Psychiatry, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip Gorwood
- Department of Psychiatry, Sainte-Anne Hospital, Paris, France
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology, National University of Singapore, Singapore
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy and Center of Brain Research, Molecular Neuroscience Branch, Medical University of Vienna, Vienna, Austria
| | - Sidney H Kennedy
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Josefina Ly-Uson
- Department of Psychiatry and Behavioral Medicine, University of The Philippines College of Medicine, Manila, The Philippines
| | - Rodrigo B Mansur
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - R Hamish McAllister-Williams
- Northern Center for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua D Rosenblat
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Gerard Sanacora
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Alan F Schatzberg
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, USA
| | - Eduard Vieta
- Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Maj Vinberg
- Mental Health Centre, Northern Zealand, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Nolan Williams
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Allan H Young
- Department of Psychological Medicine, King's College London, London, UK
| | - Mario Maj
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
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4
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Codeluppi S, Xu M, Bansal Y, Lepack A, Duric V, Chow M, Muir. J, Bagot R, Licznerski P, Wilber S, Sanacora G, Sibille E, Duman R, Pittenger C, Banasr M. Prefrontal Cortex Astroglia Modulate Anhedonia-like Behavior. RESEARCH SQUARE 2023:rs.3.rs-3093428. [PMID: 37461693 PMCID: PMC10350119 DOI: 10.21203/rs.3.rs-3093428/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Reductions of astroglia expressing glial fibrillary acidic protein (GFAP) are consistently found in the prefrontal cortex (PFC) of patients with depression and in rodent chronic stress models. Here, we examine the consequences of PFC GFAP+ cell depletion and cell activity enhancement on depressive-like behaviors in rodents. Using viral expression of diphtheria toxin receptor in PFC GFAP+ cells, which allows experimental depletion of these cells following diphtheria toxin administration, we demonstrated that PFC GFAP+ cell depletion induced anhedonia-like behavior within 2 days and lasting up to 8 days, but no anxiety-like deficits. Conversely, activating PFC GFAP+ cell activity for 3 weeks using designer receptor exclusively activated by designer drugs (DREADDs) reversed chronic restraint stress-induced anhedonia-like deficits, but not anxiety-like deficits. Our results highlight a critical role of cortical astroglia in the development of anhedonia and further support the idea of targeting astroglia for the treatment of depression.
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Affiliation(s)
- S.A. Codeluppi
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - M. Xu
- Department of Psychiatry, Yale University, New Haven, USA
| | - Y. Bansal
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - A.E. Lepack
- Department of Psychiatry, Yale University, New Haven, USA
| | - V. Duric
- Department of Psychiatry, Yale University, New Haven, USA
- Department of Physiology and Pharmacology, Des Moines University, Iowa, USA
| | - M. Chow
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - J. Muir.
- Integrated Program in Neuroscience, McGill University, Montréal, Canada
| | - R.C. Bagot
- Department of Psychology, McGill University, Montreal, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, QC, Canada
| | - P. Licznerski
- Department of Psychiatry, Yale University, New Haven, USA
- Department of Internal Medicine, Section of Endocrinology, Yale University, New Haven, USA
| | - S.L. Wilber
- Department of Psychiatry, Yale University, New Haven, USA
| | - G. Sanacora
- Department of Psychiatry, Yale University, New Haven, USA
| | - E. Sibille
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - R.S. Duman
- Department of Psychiatry, Yale University, New Haven, USA
| | - C. Pittenger
- Department of Psychiatry, Yale University, New Haven, USA
| | - M. Banasr
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
- Department of Psychiatry, Yale University, New Haven, USA
- Department of Psychiatry, University of Toronto, Toronto, Canada
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5
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Huang WL, Chiang CL, Wu CS, Liao SC, Chien TH, Tseng CH, Tang CH. Treatment patterns and healthcare utilization of patients with treatment-resistant depression estimated using health insurance database: A population-based study from Taiwan. J Affect Disord 2022; 319:40-47. [PMID: 36096374 DOI: 10.1016/j.jad.2022.08.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/18/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Determining the proportion of patients with treatment-resistant depression (TRD) among patients with unipolar depression receiving adequate pharmacological treatment (pharmaceutically treated depression [PTD]) is clinically important and may affect health care utilization. In Taiwan, these issues can be assessed by analyzing population-based data. METHODS The present study included data from the Taiwan National Health Insurance Research Database from 2010 to 2017. Among patients with depression, PTD was defined by the receipt of at least one adequate antidepressant treatment, and TRD was defined as receiving a third adequate antidepressant treatment after failure to respond to two prior treatments. Time of progression from PTD to TRD was estimated via the Kaplan-Meier function. A propensity-matched case-comparison cohort approach was used to compare resource utilization between patients with non-TRD PTD and TRD. RESULTS TRD was defined in 11.2 % of patients with unipolar depression and 37.1 % of PTD patients. The time of progression from PTD to TRD was approximately 1 year. Most TRD patients were women, middle-aged, and treated in general practice clinics. Antidepressant monotherapy, followed by antidepressant with augmentation, was the most common treatment strategy applied to TRD patients. Medical utilization was significantly higher in patients with TRD than those with non-TRD PTD across most aspects. LIMITATIONS TRD was defined based on pharmacological treatment patterns, as the reasons for changes in antidepressant regimens were not available. CONCLUSION Approximately one-third of patients with PTD developed TRD, often soon after receiving adequate pharmacological treatment. Patients with TRD used more medical resources than patients with non-TRD PTD.
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Affiliation(s)
- Wei-Lieh Huang
- Department of Psychiatry, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan; Department of Psychiatry, National Taiwan University Hospital, Taipei City 100, Taiwan; Department of Psychiatry, College of Medicine, National Taiwan University, Taipei City 100, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei City 100, Taiwan
| | - Chih-Lin Chiang
- Medical Affairs, Janssen Pharmaceutical of Johnson & Johnson, Taipei City 104, Taiwan; Medical Affairs, Janssen Pharmaceutical of Johnson & Johnson, Tokyo 101-0065, Japan
| | - Chi-Shin Wu
- Department of Psychiatry, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan; Department of Psychiatry, National Taiwan University Hospital, Taipei City 100, Taiwan; Department of Psychiatry, College of Medicine, National Taiwan University, Taipei City 100, Taiwan; National Center for Geriatrics and Welfare Research, National Health Research Institutes, Zhunan 350, Taiwan
| | - Shih-Cheng Liao
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei City 100, Taiwan; Department of Psychiatry, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu Hospital, Hsin-Chu City 300, Taiwan.
| | - Tzu-Hsiang Chien
- Market Access, Janssen Pharmaceutical of Johnson & Johnson, Taipei City 104, Taiwan; Integrated Market Access Team, Janssen-Cilag Pty Ltd., Sydney, NSW 2113, Australia
| | - Chiung-Hui Tseng
- Market Access, Janssen Pharmaceutical of Johnson & Johnson, Taipei City 104, Taiwan
| | - Chao-Hsiun Tang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei City 106, Taiwan.
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Cepeda MS, Teneralli RE, Kern DM, Novak G. Differences between men and women in response to antiseizure medication use and the likelihood of developing treatment resistant epilepsy. Epilepsia Open 2022; 7:598-607. [PMID: 35939656 PMCID: PMC9712479 DOI: 10.1002/epi4.12632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/27/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The prevalence of epilepsy is slightly higher in women than in men and sensitivity to seizure stimuli differs between sexes. Some evidence suggests sex differences in response to antiseizure medications exist mainly due to inconsistent pharmacokinetic differences; however, there is a lack of real-world evidence examining differences in response to antiseizure medications between men and women. METHODS This was a retrospective population-based cohort study in five large US healthcare databases. The population included adult patients with epilepsy, newly exposed to levetiracetam, and naive to antiseizure medication. The first exposure to levetiracetam was the index date. The requirement that all patients received the same medication was done to avoid potential confounding due to differences in index treatment. The outcome was the development of treatment resistant epilepsy (TRE), defined as having at least three distinct antiseizure medications in 1 year. The proportion of patients who developed TRE within 1 year following the index date was calculated. To compare the risk of developing TRE between sexes, relative risks (RR) and 95% confidence intervals (CI) were calculated, and estimates were pooled using meta-analytic techniques stratified by gender and age. RESULTS A total of 147 334 subjects were included in the databases, 50.8% were women, and 4.27% developed TRE. The comorbid profile differed greatly between men and women; however, the types of epilepsy syndromes observed during baseline were similar between the two groups. Across all databases, women were more likely to develop TRE than men (pooled RR 1.27, 95% CI 1.17-1.38). Results remained similar when stratified by age. SIGNIFICANCE This study assessed sex differences in response to antiseizure medications using the development of TRE as a proxy for effectiveness. Women newly exposed to levetiracetam were 27% more likely to develop TRE than men, independent of age.
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Affiliation(s)
- M. Soledad Cepeda
- Janssen Research & Development, LLC., EpidemiologyTitusvilleNew JerseyUSA
| | | | - David M. Kern
- Janssen Research & Development, LLC., EpidemiologyTitusvilleNew JerseyUSA
| | - Gerald Novak
- Janssen Research & Development, LLC., NeuroscienceTitusvilleNew JerseyUSA
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7
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Rozjabek H, Li N, Hartmann H, Fu DJ, Canuso C, Jamieson C. Assessing the meaningful change threshold of Quality of Life in Depression Scale using data from two phase 3 studies of esketamine nasal spray. J Patient Rep Outcomes 2022; 6:74. [PMID: 35816217 PMCID: PMC9273809 DOI: 10.1186/s41687-022-00453-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) directly impacts patients' lives including symptoms, functioning and health-related quality-of-life (HRQoL). Patient-reported outcomes can capture these impacts, however interpretation of clinical meaningfulness of these measurements are often not readily available. Meaningful change thresholds (MCTs) can be derived for clinical outcome assessments to quantify the change in symptoms that is meaningful to the patient following pharmacologic treatment or other interventions. The objective of this analysis was to determine the within-patient MCT of the self-reported Quality-of-Life in Depression Scale (QLDS) among patients with MDD and active suicidal ideation with intent (MDSI) using an anchor-based approach. METHODS Data from 2 randomized phase-3 trials of esketamine nasal spray (ASPIRE I and ASPIRE II) were analyzed. The Montgomery-Åsberg Depression Rating Scale (MADRS) was the primary anchor with three different severity criteria. Other anchor variables utilized were Clinical Global Impression of Severity of Suicidality-revised version, Clinical Global Impression of Imminent Suicide Risk, and EuroQol Visual Analog Scale [EQ-VAS]. Spearman correlation coefficients between the change in QLDS and anchor variables were calculated. The mean change in QLDS score at Day 25 from baseline was calculated based on the categorical change in the anchor. Coefficient yield from linear regression of the mean changes in EQ-VAS and QLDS, and distribution-based approach with ½ SD of change in QLDS were considered. RESULTS In ASPIRE I, mean (SD) improvement in QLDS score among patients with one category improvement in MADRS from baseline to Day 25 was - 8.22 (8.87), - 8.30 (9.01), and - 8.20 (8.92) using severity criteria #1, #2, and #3, respectively. Patients who achieved a 7-point improvement (MCT) in EQ-VAS yielded a mean - 9.69-point improvement in QLDS at Day 25. The ½ SD of change in QLDS was 5.63. Similar results were obtained for ASPIRE II. The MCTs identified using multiple anchors across both trials ranged from - 11.4 to - 6.7 and had an overall mean of - 7.90 (ASPIRE I) and - 7.92 (ASPIRE II). Thus, an 8-point change was recommended as the MCT for QLDS. CONCLUSION The recommended MCT will help quantify within-person changes in HRQoL using patient-reported QLDS and determine meaningful treatment benefit in an MDD patient population with acute suicidal ideation or behavior. TRIAL REGISTRATION Name of the registry: ClinicalTrials.gov. TRIAL REGISTRATION NUMBER ASPIRE I (NCT03039192), ASPIRE II (NCT03097133). Date of registration: February 01, 2017; March 31, 2017. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03039192 ; https://clinicaltrials.gov/ct2/show/NCT03097133 .
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Affiliation(s)
| | - Nan Li
- Janssen Research and Development, LLC, Horsham, PA, USA
| | - Holger Hartmann
- Health Economics and Market Access Research, Janssen-Cilag, Neuss, North Rhine-Westphalia, Germany
| | - Dong Jing Fu
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Carla Canuso
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Carol Jamieson
- Janssen Research and Development, LLC, Milpitas, CA, USA
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8
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Wang H, Wu T, Dong S, Guan M, Liu A, Jiang K, Chi R, Qiu H, Dong W, Si T. One-year incidence rate of Treatment Resistant Depression (TRD) and treatment characteristics in China. J Affect Disord 2022; 305:77-84. [PMID: 35240201 DOI: 10.1016/j.jad.2022.02.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known about the characteristics of Treatment-Resistant Depression (TRD) in China. In previous studies various identification approaches have led to a wide range of results, and it is unclear how Chinese patients compare to those in other studies. METHODS This is a retrospective cohort study using electronic health records (EHR) from two major psychiatric hospitals in China. Adult major depressive disorder (MDD) patients who initiated pharmaceutical treatment during 2010-2018 were enrolled and follow-up was 1 year. TRD was primarily identified by consensus definition of two failures of adequate (≥4 weeks) regimens. Alternative regimens of 2-weeks and 6-weeks duration, and a data-driven definition were also applied. RESULTS In the two hospitals, 12,257 (mean age: 40.8y, 63.6% female) and 8314 (mean age: 42.4y, 68.4% female) eligible patients were included. The 1-year incidence rate of TRD was estimated to be 5.2%-7.7% using the primary definition. TRD patients had mean treatment duration of 302.5 days and 285.7 days; had 3.6 and 3.7 treatment steps on average; 94.0% and 72.6% were prescribed polypharmacy regimens, which were all marginally greater than that of non-TRD patients. Alternative definitions resulted in a wide range of incidence estimates (0.5%-20.0%). LIMITATIONS Medications were assumed to be consumed as prescribed and lack of rating scales from EHRs may limit our TRD identification. CONCLUSIONS The incidence of TRD among Chinese MDD patients was comparable to other countries under similar settings and more complex treatment characteristics were observed among TRD patients. Alternative TRD definitions revealed the need for better treatment management in practices.
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Affiliation(s)
- Huaning Wang
- Department of Psychiatry, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Tao Wu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, China
| | - Sijia Dong
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, China
| | - Muzhen Guan
- Department of Psychiatry, Xijing Hospital, Air Force Medical University, Xi'an, China; Department of Mental Health, Xi'an Medical University, Xi'an, China
| | - Ao Liu
- Xian Janssen Pharmaceutical, China
| | - Kun Jiang
- Department of Psychiatry, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Rui Chi
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Hong Qiu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, USA
| | - Wentian Dong
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Tianmei Si
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.
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Tor PC, Amir N, Fam J, Ho R, Ittasakul P, Maramis MM, Ponio B, Purnama DA, Rattanasumawong W, Rondain E, Bin Sulaiman AH, Wiroteurairuang K, Chee KY. A Southeast Asia Consensus on the Definition and Management of Treatment-Resistant Depression. Neuropsychiatr Dis Treat 2022; 18:2747-2757. [PMID: 36444218 PMCID: PMC9700522 DOI: 10.2147/ndt.s380792] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD and available treatment pathways for the management of TRD vary across the Southeast Asia (SEA) region, highlighting the need for a uniform definition and treatment principles to optimize the management TRD in SEA. METHODS Following a thematic literature review and pre-meeting survey, a SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA Appropriateness Method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management. RESULTS The expert panel agreed that "pharmacotherapy-resistant depression" (PRD) is a more suitable term for TRD and defined it as "failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode". A stepwise treatment approach should be employed for the management of PRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Non-pharmacological treatments, such as electroconvulsive therapy and repetitive transcranial magnetic stimulation, are also appropriate options for patients with PRD. CONCLUSION These consensus recommendations on the operational definition of PRD and treatment principles for its management can be adapted to local contexts in the SEA countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with PRD.
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Affiliation(s)
- Phern Chern Tor
- Department of Mood and Anxiety, Institute of Mental Health, Singapore
| | - Nurmiati Amir
- Department of Psychiatry, Cipto Mangunkusumo Hospital, Jakarta Pusat, Indonesia
| | - Johnson Fam
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Roger Ho
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Pichai Ittasakul
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Margarita M Maramis
- Department of Psychiatry, Dr. Soetomo General Academic Hospital-Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Benita Ponio
- Department of Psychiatry, Metro Psych Facility, Manila, Philippines
| | | | | | - Elizabeth Rondain
- Department of Psychiatry, Makati Medical Center, Makati City, Philippines
| | - Ahmad Hatim Bin Sulaiman
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Kok Yoon Chee
- Department of Psychiatry, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
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Pérez-Sola V, Roca M, Alonso J, Gabilondo A, Hernando T, Sicras-Mainar A, Sicras-Navarro A, Herrera B, Vieta E. Economic impact of treatment-resistant depression: A retrospective observational study. J Affect Disord 2021; 295:578-586. [PMID: 34509073 DOI: 10.1016/j.jad.2021.08.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Víctor Pérez-Sola
- Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona IMIM (Hospital del Mar Medical Research Institute), Barcelona. CIBERSAM Department of Psychiatry, Univ Autonoma, Barcelona.
| | - Miquel Roca
- Institut Universitari d' Investigació en Ciències de la Salut (IUNICS), Idisba, Rediapp, University of Balearic Islands, Palma, Spain.
| | - Jordi Alonso
- Health Services Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), CIBERESP, Pompeu Fabra University, Barcelona, Spain.
| | - Andrea Gabilondo
- Mental Health and Psychiatric Care Research Group, Biodonostia Health Research Institute Osakidetza, San Sebastian, Spain.
| | | | | | | | | | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain.
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Teneralli RE, Kern DM, Cepeda MS, Gilbert JP, Drevets WC. Exploring real-world evidence to uncover unknown drug benefits and support the discovery of new treatment targets for depressive and bipolar disorders. J Affect Disord 2021; 290:324-333. [PMID: 34020207 DOI: 10.1016/j.jad.2021.04.096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/19/2021] [Accepted: 04/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Major depressive and bipolar disorders are associated with impaired quality of life and high economic burden. Although progress has been made in our understanding of the underlying pathophysiology and the development of novel pharmacological treatments, a large unmet need remains for finding effective treatment options. The purpose of this study was to identify potential new mechanisms of actions or treatment targets that could inform future research and development opportunities for major depressive and bipolar disorders. METHODS A self-controlled cohort study was conducted to examine associations between 1933 medications and incidence of major depressive and bipolar disorders across four US insurance claims databases. Presence of incident depressive or bipolar disorders were captured for each patient prior to or after drug exposure and incident rate ratios were calculated. Medications that demonstrated ≥50% reduction in risk for both depressive and bipolar disorders within two or more databases were evaluated as potential treatment targets. RESULTS Eight medications met our inclusion criteria, which fell into three treatment groups: drugs used in substance use disorders; drugs that affect the cholinergic system; and drugs used for the management of cardiovascular-related conditions. LIMITATIONS This study was not designed to confirm a causal association nor inform current clinical practice. Instead, this research and the methods employed intended to be hypothesis generating and help uncover potential treatment pathways that could warrant further investigation. CONCLUSIONS Several potential drug targets that could aid further research and discovery into novel treatments for depressive and bipolar disorders were identified.
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Affiliation(s)
- Rachel E Teneralli
- Janssen Research & Development, LLC., Epidemiology, Titusville, NJ, USA.
| | - David M Kern
- Janssen Research & Development, LLC., Epidemiology, Titusville, NJ, USA
| | - M Soledad Cepeda
- Janssen Research & Development, LLC., Epidemiology, Titusville, NJ, USA
| | - James P Gilbert
- Janssen Research & Development, LLC., Observational Health and Data Analytics, Raritan, NJ, USA
| | - Wayne C Drevets
- Janssen Research & Development, LLC., Neuroscience, San Diego, CA, USA
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12
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Cepeda MS, Kern DM, Canuso CM. At baseline patients treated with esketamine have higher burden of disease than other patients with treatment resistant depression: Learnings from a population based study. Depress Anxiety 2021; 38:521-527. [PMID: 33475213 PMCID: PMC8248018 DOI: 10.1002/da.23138] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/22/2020] [Accepted: 12/31/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION It is critical to assess who is being treated with a new marketed drug like esketamine to understand how it is used in the real-world setting and the effects of the medication. METHODS Retrospective analysis using two large U.S. health care databases that included commercially insured and Medicaid patients. Patients treated with esketamine were identified and their baseline characteristics described and compared with the baseline characteristics of patients with treatment resistant depression (TRD) and with patients undergoing transcranial magnetic stimulation (TMS). To quantify the differences, standardized mean differences were calculated. RESULTS In the commercially insured database, 418 patients were treated with esketamine and 830,047 patients were in the TRD group. Large differences in baseline characteristics were observed. Patients in the esketamine group were more likely to have severe depression, suicidal thoughts, and prior treatments with TMS or electroconvulsive therapy than the TRD control group. Patients in the esketamine group had more comorbid psychiatric conditions (anxiety disorder, posttraumatic stress disorders, substance use disorders) and higher exposure to antipsychotics, antiepileptics, hypnotics and sedatives. In terms of general health, patients in the esketamine group had many more outpatient visits, were more likely to have chronic pain and higher Charlson comorbidity scores, a predicator of mortality. Results were similar for both the Medicaid and TMS populations. CONCLUSION Patients treated with esketamine have a higher burden of disease than other patients with TRD. In any real-world comparative effectiveness or safety study these differences need to be understood and accounted for to produce valid results.
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Affiliation(s)
- M. Soledad Cepeda
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUSA
| | - David M. Kern
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUSA
| | - Carla M. Canuso
- Department of NeuroscienceJanssen Research & DevelopmentTitusvilleNew JerseyUSA
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13
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Döme P, Kunovszki P, Takács P, Fehér L, Balázs T, Dede K, Mulhern-Haughey S, Barbreau S, Rihmer Z. Clinical characteristics of treatment-resistant depression in adults in Hungary: Real-world evidence from a 7-year-long retrospective data analysis. PLoS One 2021; 16:e0245510. [PMID: 33471854 PMCID: PMC7817060 DOI: 10.1371/journal.pone.0245510] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/30/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose Treatment-resistant depression (TRD) is associated with a poor quality of life and high economic burden. This observational retrospective epidemiological study aimed to estimate the proportion of patients with TRD within a cohort of patients with major depressive disorder (MDD) in Hungary and examine the mortality and comorbidities of patients with and without TRD. Patients and methods This study included patients with MDD who experienced onset of a new depressive episode between 01 January 2009 and 31 August 2015, using data from a nationwide, longitudinal database. Results Overall, 99,531 patients were included in the MDD cohort, of which 8,268 (8.3%) also met the criteria for TRD. The overall survival of non-TRD patients was longer than in TRD patients; the risk of mortality for TRD patients was significantly higher than of non-TRD patients (HR [CI] 1.381 [1.212–1.571]; p<0.001). Patients with TRD had a significantly higher probability of having “Neurotic, stress-related and somatoform disordersˮ, autoimmune conditions, cardio- or cerebrovascular diseases, thyroid gland diseases and self-harming behaviour not resulting in death than non-TRD patients (for all comparisons, p values were less than 0.005). Discussion To our best knowledge, this is the first study to assess the frequency of TRD in Hungary. In a cohort of Hungarian MDD patients, we have found that the proportion of TRD (~8.3%) is comparable to those reported in previous studies with similar methodology from other countries. The majority of our other main findings (e.g. more frequent self-harming behaviour, increased risk of “Neurotic, stress-related and somatoform disordersˮ and higher overall mortality in TRD subjects) are also in line with previous results from other countries. Taking the substantial proportion of patients with TRD into consideration, a more comprehensive and targeted treatment strategy would be required for these individuals.
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Affiliation(s)
- Péter Döme
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
- Nyírő Gyula National Institute of Psychiatry and Addictions, Budapest, Hungary
| | - Péter Kunovszki
- Janssen Global Commercial Strategy Organization, Budapest, Hungary
- * E-mail:
| | - Péter Takács
- Janssen Global Commercial Strategy Organization, Budapest, Hungary
| | | | | | | | | | | | - Zoltán Rihmer
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
- Nyírő Gyula National Institute of Psychiatry and Addictions, Budapest, Hungary
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Abstract
BACKGROUND Depression and post-traumatic stress disorder (PTSD) are leading causes of disability and loss of life by suicide. Currently, there are less than satisfactory medical solutions to treat these mental disorders. Here, we explore recent preclinical and clinical studies demonstrating the potential of using buprenorphine to treat major depressive disorder, treatment-resistant depression, and PTSD. METHOD Bibliographic databases were searched to include preclinical and clinical studies demonstrating the therapeutic potential of buprenorphine and the involvement of the kappa opioid receptor (KOR) in mediating these effects. RESULTS Original clinical studies examining the effectiveness of buprenorphine to treat depression were mixed. The majority of participants in the PTSD studies were males and suffer from chronic pain and/or substance use disorders. Nonetheless, these recent studies and analyses established proof of concept warranting farther investigations. Additionally, KOR likely mediates the antidepressant and some of the anxiolytic effects of buprenorphine. Still, it appears that the full spectrum of buprenorphine's beneficial effects might be due to activity at other opioid receptors as well. CONCLUSIONS Pharmaceuticals' abilities to treat medical conditions directly relates to their ability to act upon the endogenous biological systems related to the conditions. Thus, these recent findings are likely a reflection of the central role that the endogenous opioid system has in these mental illnesses. Further studies are necessary to study the involvement of endogenous opioid systems, and specifically KOR, in mediating buprenorphine's beneficial effects and the ability to treat these medical conditions while minimizing risks for misuse and diversion.
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Affiliation(s)
- Caitlin A Madison
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX77843, USA
| | - Shoshana Eitan
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX77843, USA
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15
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Cepeda MS, Kern DM, Nicholson S. Treatment resistant depression in women with peripartum depression. BMC Pregnancy Childbirth 2019; 19:323. [PMID: 31477032 PMCID: PMC6721276 DOI: 10.1186/s12884-019-2462-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Peripartum depression is a leading cause of disease burden for women and yet there is little evidence as to how often peripartum depression does not respond to treatment and becomes treatment resistant depression. We sought to determine the incidence of treatment resistant depression (TRD) in women with peripartum depression. METHODS Population based retrospective cohort study using a large US claims database. Peripartum depression was defined as having a depression diagnosis during pregnancy or up to 6 months after the end of pregnancy. We included women with prevalent or incident depression. The outcome was the development of TRD within 1 year after the diagnosis of peripartum depression. TRD was defined as having 3 distinct antidepressants or 1 antidepressant and 1 antipsychotic in 1 year. Women with peripartum depression may not be exposed to pharmacological treatments early in pregnancy, therefore we created two groups: 1. women with peripartum depression, and 2. women with peripartum depression diagnosed 3 months before a live birth delivery or within 6 months after that delivery. RESULTS There were 3,207,684 pregnant women, of whom 2.5% had peripartum depression. Of these women half had incident depression during pregnancy. Five percent of women with peripartum depression developed TRD within 1 year of the depression diagnosis. The risk of developing TRD was 50% higher in women with prevalent depression than in women with incident peripartum depression (P < 0.0001). Results were similar in women with peripartum depression diagnosed later in their pregnancy. Women who went on to develop TRD had more substance use disorders, anxiety, insomnia and painful conditions. CONCLUSIONS TRD occurs in approximately 5% of women with peripartum depression. The risk of TRD is higher in pregnant women with a history of depression. Women who went on to develop TRD had more psychiatric comorbidities and painful conditions than women who did not.
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Affiliation(s)
- M. Soledad Cepeda
- Janssen Research and Development, 1125 Trenton Harbourton Rd, Titusville, NJ 08560 USA
| | - David M. Kern
- Janssen Research and Development, 1125 Trenton Harbourton Rd, Titusville, NJ 08560 USA
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Cepeda MS, Reps J, Ryan P. Finding factors that predict treatment-resistant depression: Results of a cohort study. Depress Anxiety 2018; 35:668-673. [PMID: 29786922 PMCID: PMC6055726 DOI: 10.1002/da.22774] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/16/2018] [Accepted: 04/23/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Treatment for depressive disorders often requires subsequent interventions. Patients who do not respond to antidepressants have treatment-resistant depression (TRD). Predicting who will develop TRD may help healthcare providers make more effective treatment decisions. We sought to identify factors that predict TRD in a real-world setting using claims databases. METHODS A retrospective cohort study was conducted in a US claims database of adult subjects with newly diagnosed and treated depression with no mania, dementia, and psychosis. The index date was the date of antidepressant dispensing. The outcome was TRD, defined as having at least three distinct antidepressants or one antidepressant and one antipsychotic within 1 year after the index date. Predictors were age, gender, medical conditions, medications, and procedures 1 year before the index date. RESULTS Of 230,801 included patients, 10.4% developed TRD within 1 year. TRD patients at baseline were younger; 10.87% were between 18 and 19 years old versus 7.64% in the no-TRD group, risk ratio (RR) = 1.42 (95% confidence interval [CI] 1.37-1.48). TRD patients were more likely to have an anxiety disorder at baseline than non-TRD patients, RR = 1.38 (95% CI 1.35-1.14). At 3.68, fatigue had the highest RR (95% CI 3.18-4.25). TRD patients had substance use disorders, psychiatric conditions, insomnia, and pain more often at baseline than non-TRD patients. CONCLUSION Ten percent of subjects newly diagnosed and treated for depression developed TRD within a year. They were younger and suffered more frequently from fatigue, substance use disorders, anxiety, psychiatric conditions, insomnia, and pain than non-TRD patients.
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Affiliation(s)
- M Soledad Cepeda
- Department of Epidemiology, Janssen Research and Development, Titusville, Florida
| | - Jenna Reps
- Department of Epidemiology, Janssen Research and Development, Titusville, Florida
| | - Patrick Ryan
- Department of Epidemiology, Janssen Research and Development, Titusville, Florida
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Cepeda MS, Reps J, Fife D, Blacketer C, Stang P, Ryan P. Finding treatment-resistant depression in real-world data: How a data-driven approach compares with expert-based heuristics. Depress Anxiety 2018; 35:220-228. [PMID: 29244906 PMCID: PMC5873404 DOI: 10.1002/da.22705] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/01/2017] [Accepted: 11/13/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Depression that does not respond to antidepressants is treatment-resistant depression (TRD). TRD definitions include assessments of treatment response, dose and duration, and implementing these definitions in claims databases can be challenging. We built a data-driven TRD definition and evaluated its performance. METHODS We included adults with depression, ≥1 antidepressant, and no diagnosis of mania, dementia, or psychosis. Subjects were stratified into those with and without proxy for TRD. Proxies for TRD were electroconvulsive therapy, deep brain, or vagus nerve stimulation. The index date for subjects with proxy for TRD was the procedure date, and for subjects without, the date of a randomly selected visit. We used three databases. We fit decision tree predictive models. We included number of distinct antidepressants, with and without adequate doses and duration, number of antipsychotics and psychotherapies, and expert-based definitions, 3, 6, and 12 months before index date. To assess performance, we calculated area under the curve (AUC) and transportability. RESULTS We analyzed 33,336 subjects with no proxy for TRD, and 3,566 with the proxy. Number of antidepressants and antipsychotics were selected in all periods. The best model was at 12 months with an AUC = 0.81. The rule transported well and states that a subject with ≥1 antipsychotic or ≥3 antidepressants in the last year has TRD. Applying this rule, 15.8% of subjects treated for depression had TRD. CONCLUSION The definition that best discriminates between subjects with and without TRD considers number of distinct antidepressants (≥3) or antipsychotics (≥1) in the last year.
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Affiliation(s)
| | - Jenna Reps
- Janssen Research and DevelopmentTitusvilleNJUSA
| | - Daniel Fife
- Janssen Research and DevelopmentTitusvilleNJUSA
| | | | - Paul Stang
- Janssen Research and DevelopmentTitusvilleNJUSA
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