Clinical effectiveness: the importance of psychosocial functioning outcomes

Relationship between cognitive function and functional outcomes in remitted major depression

BACKGROUND

Few studies have focused on functional impairment in depressed patients during symptomatic remission. The exact relationship between cognitive performance and functional outcomes of patients with Major depressive disorder (MDD) remains unclear.

METHODS

Participants diagnosed with MDD were included and interviewed at both baseline and follow-up. Cognitive function was assessed during acute episodes using the Cambridge Neuropsychological Test Automated Battery (CANTAB), which targeted attention (Rapid Visual Processing - RVP), visual memory (Pattern Recognition Memory - PRM), and executive function (Intra-Extra Dimensional Set Shift - IED). The 17-item Hamilton Depression Scale (HAMD) was used for symptom assessment. Participants were divided into two groups based on their SDSS (Social Disability Screening Schedule) scores, and the differences between their demographic information, HAMD scores, and baseline CANTAB test results were compared. Logistic regression analysis was used to identify cognitive predictors of social function during symptomatic remission.

RESULTS

According to the SDSS score at follow-up, 103 patients were divided into the normal social function group (n = 81,78.6%) and the poor social function group (n = 22, 21.4%) during clinical remission. Participants with poorer social function performed worse in the visual memory (PRM) and executive function tests (IED) at the baseline. Logistic regression analysis suggested that performance on the PRM (95%CI = 0.31-0.93, p = 0.030) and IED (95%CI = 1.01-1.13, p = 0.014) tests, instead of less severe symptoms, significantly contributed to functional outcomes.

CONCLUSION

Better performance in visual memory and executive function during acute episodes may predict better social functional outcomes in individuals with MDD. A potential early intervention to improve social function in individuals with MDD could include the treatments for executive function and visual memory.

IMproving psYchosocial adjustment to Traumatic Brain Injury from acute to chronic injury through development and evaluation of the myTBI online psychoeducation platform: protocol for a mixed-methods study

INTRODUCTION

This protocol describes the myTBI study which aims to: (1) develop an online psychoeducation platform for people with traumatic brain injury (TBI), their family members/caregivers, and healthcare staff to improve psychosocial adjustment to TBI across different phases of injury (acute, postacute, and chronic), and (2) undertake an evaluation of efficacy, acceptability, and feasibility.

METHODS AND ANALYSIS

A three-stage mixed-methods research design will be used. The study will be undertaken across four postacute community-based neurorehabilitation and disability support services in Western Australia. Stage 1 (interviews and surveys) will use consumer-driven qualitative methodology to: (1) understand the recovery experiences and psychosocial challenges of people with TBI over key stages (acute, postacute, and chronic), and (2) identify required areas of psychosocial support to inform the psychoeducation platform development. Stage 2 (development) will use a Delphi expert consensus method to: (1) determine the final psychoeducation modules, and (2) perform acceptance testing of the myTBI platform. Finally, stage 3 (evaluation) will be a randomised stepped-wedge trial to evaluate efficacy, acceptability, and feasibility. Outcomes will be measured at baseline, postintervention, follow-up, and at final discharge from services. Change in outcomes will be analysed using multilevel mixed-effects modelling. Follow-up surveys will be conducted to evaluate acceptability and feasibility.

ETHICS AND DISSEMINATION

Ethics approval was granted by North Metropolitan Health Service Mental Health Research Ethics and Governance Office (RGS0000005877). Study findings will be relevant to clinicians, researchers, and organisations who are seeking a cost-effective solution to deliver ongoing psychoeducation and support to individuals with TBI across the recovery journey.

TRIAL REGISTRATION NUMBER

ACTRN12623000990628.

If you feel you can't, you won't: the role of subjective and objective cognitive competence on psychosocial functioning in depression

BACKGROUND

The purpose of this exploratory study is to examine the role of sociodemographic, clinical, and cognitive - both objective and subjective - factors in overall and in specific domains of psychosocial functioning, in patients with depression at different clinical states of the disease (remitted and non-remitted).

METHODS

A sample of 325 patients with major depressive disorder, 117 in remission and 208 in non-remission, were assessed with a semi-structured interview collecting sociodemographic, clinical, cognitive (with neuropsychological tests and the Perceived Deficit Questionnaire), and functional (Functioning Assessment Short Test) characteristics. Backward regression models were conducted to determine associations of global and specific areas of functioning with independent factors, for both clinical states.

RESULTS

Residual depressive symptomatology and self-appraisal of executive competence were significantly associated with psychosocial functioning in remitted patients, in overall and some subdomains of functioning, particularly cognitive and interpersonal areas. While depressive symptoms, executive deficits and self-appraisal of executive function were significantly related to functional outcomes in non-remitted patients, both in overall functioning and in most of subdomains.

DISCUSSION

This study evidences the strong association of one's appraisal of executive competence with psychosocial functioning, together with depressive symptoms, both in remitted and non-remitted patients with depression. Therefore, to achieve full recovery, clinical management of patients should tackle not only the relief of core depressive symptoms, but also the cognitive ones, both those that are objectified with neuropsychological tests and those that are reported by the patients themselves.

Health-related quality of life of children with first onset steroid-sensitive nephrotic syndrome

This study assessed HRQoL and emotional and behavioral difficulties (EBD) and associated variables in children with first onset SSNS. While relapsing steroid-sensitive nephrotic syndrome (SSNS) in children is associated with lower health-related quality of life (HRQoL), little is known about first onset. Four weeks after onset, children (2-16 years) and/or their parents who participated in a randomized placebo-controlled trial, completed the Pediatric Quality of Life Inventory 4.0 (PedsQL) and Strengths and Difficulties Questionnaire (SDQ) to measure HRQoL and EBD, respectively. Total and subscale scores and the proportion of children with impaired HRQoL (> 1 SD below the mean of the reference group) or SDQ clinical scores (< 10th and > 90th percentile) were compared to the Dutch general population (reference group). Regression analyses were used to identify associated variables. Compared to the reference group, children 8-18 years reported significantly lower total HRQoL, and physical and emotional functioning. A large proportion (> 45%) of these children had impaired HRQoL. There were no differences in HRQoL between children 2-7 years and the reference group, except for higher scores on social functioning (5-7 years). Similar proportions of SSNS and reference children scored within the clinical range of SDQ subscales. Age, sex, and steroid side-effects were negatively associated with HRQol and/or EBD.   Conclusion: This study showed that HRQoL and EBD are affected in children of different ages with first onset SSNS. This calls for more awareness from healthcare providers and routinely monitoring of HRQoL and EBD in daily clinical care to prevent worsening of symptoms.   Clinical trial registry: Netherlands Trial Register ( https://trialsearch.who.int/ ; NTR7013), date of registration: 02 June 2018. What is Known: •  Health-related quality of life (HRQoL) is lower and emotional and behavioral difficulties (EBD) is more affected in children with frequently-relapsing and steroid-dependent nephrotic syndrome. What is New: •  HRQoL and EBD are affected in children with first onset steroid-sensitive nephrotic syndrome compared to a reference group of the Dutch general population. • To what extent HRQoL and EBD are affected depends on the age of the patient.

Worry, rumination and negative metacognitive beliefs as moderators of outcomes of Transdiagnostic group cognitive-behavioural therapy in emotional disorders

BACKGROUND

Despite the relevance of cognitive processes such as rumination, worry, negative metacognitive beliefs in emotional disorders, the existing literature about how these cognitive processes moderate the effect of treatment in treatment outcomes is limited. The aim of the present study was to explore the potential moderator effect of baseline cognitive processes-worry, rumination and negative metacognitive beliefs-on the relationship between treatment allocation (transdiagnostic cognitive-behavioural therapy -TD-CBT plus treatment as usual-TAU vs. TAU alone) and treatment outcomes (anxiety and depressive symptoms, quality of life [QoL], and functioning) in primary care patients with emotional disorders.

METHODS

A total of 631 participants completed scales to evaluate worry, rumination, negative metacognitive beliefs, QoL, functioning, and anxiety and depressive symptoms.

RESULTS

Worry and rumination acted as moderators on the effect of treatment for anxiety (b = -1.25, p = .003; b = -0.98, p = .048 respectively) and depressive symptoms (b = -1.21, p = .017; b = -1.34, p = .024 respectively). Individuals with higher baseline levels of worry and rumination obtained a greater reduction in emotional symptoms from the addition TD-CBT to TAU. Negative metacognitive beliefs were not a significant moderator of any treatment outcome.

LIMITATIONS

The study assesses cognitive processes over a relatively short period of time and uses self-reported instruments. In addition, it only includes individuals with mild or moderate anxiety or depressive disorders, which limits generalization to other populations.

CONCLUSIONS

These results underscore the generalization of the TD-CBT to individuals with emotional disorders in primary care with different cognitive profiles, especially those with high levels of worry and rumination.

Treating depression in clinical practice: new insights on the multidisciplinary use of trazodone

Depression is estimated to be a leading contributor to the global mental health-related burden. The determinants of this huge prevalence lie in the fact that depressive symptoms may be comorbid in a wide variety of disorders, thus complicating and exacerbating their clinical framework. This makes the treatment of depressive symptoms difficult, since many pharmacological interactions should be considered by physicians planning therapy. Hence, depression still represents a challenge for both psychiatrists and other clinicians, in terms of its high rates of relapse and resistance despite well-established protocols. It is also complicated by the well-known latency in its complete response to current antidepressant treatments. In this context, the search for new strategies regarding antidepressant treatment is mandatory. Revising the use of "old" pharmacotherapies by considering their specific features may help to perfecting the treatment of depression, both in its standalone psychiatric manifestation and in the framework of other clinical conditions. Using a nominal group technique approach, the results of a consensus of expert physicians regarding the possible use of trazodone as a valuable strategy for addressing the "real world" unmet needs of depression treatment in different fields (psychiatry, primary care, neurology and geriatrics) is herein provided. This idea is based on the unique characteristics of this drug which delivers a more rapid antidepressant action as compared to other selective serotonin reuptake inhibitors. It also has pharmacodynamic malleability (i.e., the possibility of exerting different effects on depressive symptoms at different dosages) and pharmacokinetic tolerability (i.e., the possibility of being used as an add-on to other antidepressants with scarce interaction and achieving complimentary effects) when used in the milieu of other drugs in treating comorbid depressive symptoms. Moreover, the large number of formulations available permits finite dosage adjustments, and the use of trazodone for specific pathologies, such as dysphagia. Therefore, although additional studies exploring the real-world conditions of antidepressant treatment are warranted, experts agree on the idea that depressive disorder, in both its standalone and its comorbid manifestations, may surely take advantage of the particular characteristics of trazodone, thus attempting to reach the greatest effectiveness in different contexts.

Predictors of functional impairment at assessment and functional improvement after treatment at a national digital mental health service

Mental disorders are associated with impairment to daily functioning, which affects both the individual and society. Despite this, most research on treatment outcome only report symptom change. Self-reported days out of role (DOR) is a simple measure of functional impairment used in many population studies. The current study sought to report on the degree of functional impairment measured by DOR in a clinical sample at assessment, the factors associated with this impairment, the predictors of functional improvement after treatment and the relationship between symptomatic and functional change. Using a prospective uncontrolled observational cohort study design with a sample of 17,813 patients accessing a digital mental health service (DMHS), we examined self-reported demographic, psychosocial and clinical data. Using a series of univariate regression models and multivariate classification algorithms, we found that baseline DOR was associated with age, employment and relationship status, symptom severity, symptom chronicity and with the presence of several psychosocial difficulties. Baseline DOR was best predicted by older age, disability payments, higher symptom severity and increasing number of endorsed psychosocial difficulties (R² = 32.7 %). Forty-one per cent of the sample experienced a >50 % or greater reduction in DOR following treatment. Those who were separated, unemployed or on disability payments, or with severe and chronic depression, experienced the greatest reductions in DOR after treatment. Changes in functioning were independent of changes in symptoms, highlighting the importance of functional impairment as a treatment outcome. This study found that many of the patients who access DMHS have significant levels of functional impairment, a large proportion obtain functional improvement after treatment, and improvement in function after treatment was independent of improvement in symptoms.

Psychosocial functioning of adolescents with ADHD in the family, school and peer group: A scoping review protocol

Objective

The objective of this scoping review is to investigate what is known about the psychosocial functioning of adolescents with ADHD. All basic life environments (family, school and peer group) will be considered.

Introduction

Adolescence is especially critical for people with ADHD–natural maturation may be accompanied by changing symptoms of ADHD. A number of childhood difficulties transform during adolescence and contribute to problems in various areas that comprise psychosocial functioning. The available studies focus on selected domains of psychosocial functioning of adolescents with ADHD, however, to the authors’ best knowledge, there is no comprehensive description of this issue. The lack of such a description is the main rationale for conducting this scoping review.

Inclusion criteria

Pointing to the PCC elements (population, concept, context), the scoping review will include primary studies on the concept of psychosocial functioning (including functioning in the family, school and peer group). In the included studies, the term "psychosocial functioning" (or related) had to be used explicitly. The population will be adolescents (10 to 19 years old) with a formal diagnosis of ADHD (DSM classification) or Hyperkinetic Syndrome (ICD-9) or Hyperkinetic Disorders (ICD-10). There will be no restrictions on the research context.

Methods

The methodology of scoping reviews will be applied in accordance with the guidelines of the Joanna Briggs Institute (JBI). The following databases: Academic Search Ultimate, ERIC, MEDLINE, ProQuest Central, PsycInfo, Scopus, and databases under the Web of Science will be searched for primary studies in peer-reviewed journals, written in English and published since 1987. The analyses will be based mainly on frequency counts of the components of psychosocial functioning and population characteristics. The results will be presented in tabular form and supplemented with a descriptive summary. The protocol has been registered on the Open Science Framework: https://doi.org/10.17605/OSF.IO/MS82H [registration DOI].

Functional status and return to work in people with major depression: a 3-year national follow-up study

PURPOSE

Major depressive disorder (MDD) affects a person's function of daily activities, including work participation. Such functional impairments often persist even when other symptoms of MDD are remitted. Increasing evidence highlights the health-promoting effects of returning to work (RTW) in various diseases. However, limited data are available regarding the impact of return to work on functional recovery in MDD. We explored the association between RTW and functional improvements in people with MDD using a large nationally representative database and a 3-year follow-up.

METHODS

Data of people with an MDD diagnosis were selected from the Taiwan Data Bank of Persons with disability for the period between July 11, 2012, and October 31, 2018. We included 4038 adults aged 18-64 years. The World Health Organization Disability Assessment Schedule 2.0 was used for functional assessment. The association between RTW and functional improvements was investigated using a multivariable regression analysis adjusted for confounding variables.

RESULTS

Women aged ≥ 45 years with a lower education level were vulnerable to prolonged unemployment. RTW was significantly associated with better functional improvements in cognition, mobility, self-care, getting along, life activity, and participation than unemployment.

CONCLUSIONS

RTW was positively associated with functional improvements in patients with MDD. A referral system targeting re-employment may be suggested during MDD treatment, especially for individuals at risk of prolonged unemployment.

Development of a psychosocial functioning questionnaire for patients with major depressive disorder

Background

The importance of psychosocial functioning in the assessment, diagnosis and treatment of major depressive disorder (MDD) is widely recognised. However, there is a lack of effective scales to assess psychosocial functioning in patients with MDD.

Aims

To develop a professional questionnaire to evaluate the psychosocial functioning of patients with MDD.

Methods

Using a literature review, an open-ended questionnaire survey, and patient interviews, a theoretical model of psychosocial functioning was constructed, and an initial questionnaire was formed which included four dimensions. After two rounds of testing, using items analysis and exploratory factor analysis, a finalized questionnaire was created. There were 460 patients with MDD selected from six psychiatric hospitals for formal testing using a convenience sampling method. Forty patients were randomly selected and retested one week later to evaluate the test-retest reliability of the scale. The Patient Health Questionnaire-9 (PHQ-9), Short Form of Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF), Sheehan Disability Scale (SDS), and Dysfunctional Attitudes Scale (DAS) provided major standards to check the criterion validity of this questionnaire. Correlation analysis, confirmatory factor analysis, and internal consistency reliability testing were used to examine other psychometric characteristics of the finalized questionnaire.

Results

The Psychosocial Functioning Questionnaire (PFQ) for patients with MDD included three dimensions: psychological cognitive functioning, subjective well-being, and social functioning, with a total of 18 items. The overall internal consistency reliability of the questionnaire was 0.957, and the test-retest reliability was 0.840. Confirmatory factor analysis showed that the model fitted well: Goodness of Fit Index (GFI)=0.888; Root Mean SquareError of Approximation (RMSEA)=0.085. The total score of PFQ was significantly correlated with the total score of PHQ-9, DAS, SDS and Q-LES-Q-SF (|r|=0.599-0.870, p<0.001).

Conclusions

The Psychosocial Functioning Questionnaire has good reliability and validity. It can be used to measure the psychosocial functioning of patients with MDD.

Functional outcomes with bright light in monotherapy and combined with fluoxetine in patients with major depressive disorder: Results from the LIFE-D trial

BACKGROUND

Bright light therapy has been shown to improve depressive symptoms in patients with nonseasonal major depressive disorder (MDD) but there are few studies examining functional outcomes.

METHODS

We examined secondary functional outcomes in the 8-week randomized, placebo-sham-controlled LIFE-D trial comparing light therapy, fluoxetine, and the combination in patients with nonseasonal MDD. Functional assessments included the Sheehan Disability Scale (SDS) and, for employed participants, the Lam Employment Absence and Productivity Scale (LEAPS). Analysis of covariance (ANCOVA) was conducted with SDS and LEAPS change scores from baseline to week 8 as dependent variables, treatment modality (light, fluoxetine) as an independent variable, and baseline SDS and LEAPS scores as covariates.

RESULTS

Of 122 randomized participants, SDS data were available for 105 and LEAPS data for 70. For the SDS, there were no interaction effects, but there was a significant small- to medium-sized main effect of light treatment on total SDS scores with corresponding significant effects in the Social Life and Family Life domains, but not in the Work/Study domain. There were no significant interaction or main effects with LEAPS scores.

CONCLUSION

Light therapy significantly improved social and family life functioning in patients with MDD. However, work functioning was not significantly improved despite large effect sizes; these results were limited by low statistical power because of small sample sizes. Future studies should use longer treatment durations and be powered to detect clinically relevant differences in functional outcomes.

Remission of symptoms is not equal to functional recovery: Psychosocial functioning impairment in major depression

The ultimate goal of depression treatment is to achieve functional recovery. Psychosocial functioning is the main component of functional impairment in depressed patients. The concept of psychosocial functioning has an early origin; however, its concept and connotation are still ambiguous, which is the basic and key problem faced by the relevant research and clinical application. In this study, we start from the paradox of symptoms remission and functional recovery, describe the concept, connotation, and characteristics of psychosocial functioning impairment in depressed patients, and re-emphasize its importance in depression treatment to promote research and clinical applications related to psychosocial functioning impairment in depressed patients to achieve functional recovery.

Neural biomarker of functional disability in major depressive disorder: A structural neuroimaging study

BACKGROUND

Most patients with the major depressive disorder (MDD) have varying degrees of impaired social functioning, and functional improvement often lags behind symptomatic improvement. However, it is still unclear if certain neurobiological factors underlie the deficits of social function in MDD. The aim of this study was to investigate the biomarkers of social function in MDD using structural magnetic resonance imaging (MRI).

METHODS

3T anatomical MRI was obtained from 272 subjects including 46 high-functioning (high-SF, Sheehan Disability Scale (SDS) rating < 18) and 63 low-functioning (low-SF, SDS score ≥ 18) patients with MDD and 163 healthy controls (HC). Voxel-based morphometry (VBM) was employed to locate brain regions with grey matter (GM) volume differences in relation to social function in MDD. Regions showing GM differences in relation to social function at baseline were followed up longitudinally in a subset of 38 patients scanned after 12-week treatment.

RESULTS

Volume of right parahippocampal gyrus (rPHG) was significantly reduced in low-SF patients with MDD when compared to high-SF ones (FDR-corrected p < 0.05). Over 12 weeks of follow-up, though SF improved overall, the high and low-SF subgroups continued to differ in their SF, but had no progressive changes in PHG volume.

LIMITATIONS

Limited functional assessment, high drop-out rate and median-based grouping method.

CONCLUSIONS

Greater GM volume (GMV) of the rPHG may mark better social function in patients with MDD.

Neuroprotective Effect of Apigenin on Depressive-Like Behavior: Mechanistic Approach

Apigenin, as a natural flavonoid present in several plants is characterized with potential anticancer, antioxidant, and anti-inflammatory properties. Recent studies proposed that apigenin affects depression disorder through unknown mechanistic pathways. The effects of apigenin's anti-depressive properties on streptozocin-mediated depression have been investigated through the evaluation of behavioral tests, oxidative stress, cellular energy homeostasis and inflammatory responses. The results demonstrated anti-depressive properties of apigenin in behavioral test including forced swimming and splash tests and oxidative stress biomarkers such as reduced glutathione, lipid peroxidation, total antioxidant power and coenzyme Q₁₀ levels. Apigenin, also, demonstrated its regulatory potency in cellular energy homeostasis and immune system gene expression through inhibiting Nlrp3 and Tlr4 overexpression. Furthermore, failure in energy production as the key factor in various psychiatric disorders was reversed by apigenin modulating effect on AMPK gene expression. Overall, 20 mg/kg of apigenin was recognized as the dose suitable for minimizing the undesirable adverse effects in the STZ-mediated depression model proposed in this study. Our data suggested that apigenin could be able to adjust behavioral dysfunction, biochemical biomarkers and recovered cellular antioxidant level in depressed animals. The surprising results were achieved by raise in COQ₁₀ level, which could regulate the overexpression of the AMPK gene in stressful conditions. The regulatory effect of apigenin in inflammatory signaling pathways such as Nlrp3, and Tlr4 gene expression was studied at the surface part of the hippocampus.

Functional Disability in Psychiatric Patients With Deliberate Self-Harm as Compared to a Clinical Control Group

Background: Deliberate self-harm (DSH) is a common behavior in psychiatric populations. However, little is known regarding how DSH impacts daily life. The concept of functional disability, adopted by the World Health Organization (WHO), refers to the impact of disorders on six domains of daily functioning. The aim of the current study was to explore the functional disability of psychiatric patients with DSH as compared to a psychiatric control group. Methods: 32 psychiatric patients with DSH and 31 psychiatric patients without DSH were assessed with regards to demographic information, functional disability, psychiatric illness, DSH, general cognitive functioning, and measures of psychopathology. Group comparisons were made by means of t-tests, Mann-Whitney-tests, and Chi-square tests. Correlation analyses were done to assess the association between measures of psychopathology and functional disability. Results: The results indicated that patients with DSH had a lower ability to self-care as compared to the patients without DSH (p = 0.001, d = 0.90). Also, the patients with DSH reported a significantly higher number of days when they were totally unable to carry out usual activities in the past month (p = 0.008, d = 0.70) and that they were admitted in an inpatient setting significantly more days over the past year compared to the patients without DSH (p < 0.001, d = 0.58). The group with DSH was significantly younger (t = 3.00, p = 0.004) and reported significantly more BPD-symptoms (p = 0.013, d = 0.64) as well as higher current suicidality (p < 0.001, d = 1.32) compared to the group without DSH. The group with DSH also included a significantly higher number of patients diagnosed with borderline personality disorder (χ2 = 13.72, p < 0.001). There were no differences between the groups regarding general cognitive functioning or severity of depression. More research is needed to understand the underlying factors involved.

Anhedonia predicts poor psychosocial functioning: Results from a large cohort of patients treated for major depressive disorder by general practitioners

Background:

Anhedonia is a core symptom of major depression and a key prognostic factor that is often poorly explored in clinical trials of major depressive disorder (MDD). Beyond symptomatic remission, psychosocial functioning also reveals difficulty in achieving remission in patients with MDD. The main objective of this study was to explore the interrelationships between social functioning and anhedonia on a longitudinal basis.

Methods:

In total, 1570 outpatients treated for MDD with agomelatine were included. Severity of depression and levels of anhedonia and of psychosocial functioning were assessed at inclusion and at 10–14 weeks, with specific standardized scales (MADRS, QFS, SHAPS, CGI). Multivariate regression and mediation analyses were performed.

Results:

Using multivariate regression, we showed that improvement of anhedonia was the strongest predictor of improvement in psychosocial functioning (odds ratio = 7.3 [4.3–12.1] P < 0.0001). In addition, mediation tests confirmed that the association between improvement of depressive symptoms and improvement of social functioning was significantly underpinned by the improvement of anhedonia over time. Finally, we explored the determinants of the dissociation of the response, i.e., the persistence of psychosocial dysfunctioning despite a symptomatic response to antidepressant treatment, which remains a widespread situation in clinical practice. We showed that this dissociation was strongly predicted by persistence of anhedonia.

Conclusion:

Our results suggest that anhedonia is one of the strongest predictors of psychosocial functioning, along with symptomatic remission, and should be carefully assessed by health professionals, in order to optimize pharmacological as well as non-pharmacological management of depression.

Polymorbidity of developmental disabilities: Additive effects on child psychosocial functioning and parental distress

BACKGROUND

While parents of children with developmental disabilities show greater parenting burden and distress compared with their counterparts, little is known about to what extent developmental polymorbidity in children escalates and magnifies the risk of parental distress.

AIMS

This study investigated the co-occurrence of developmental disabilities among a sample of elementary school children and examined its additive effects on child psychosocial functioning and parental distress.

METHODS AND PROCEDURES

A cross-sectional survey among 710 parents of elementary school children in Hong Kong included measures of child psychosocial functioning and parental stress. Structural equation modeling was used to test a hypothesized model in which child psychosocial functioning mediates the effect of developmental polymorbidity on parental distress.

OUTCOMES AND RESULTS

About one-fourth of the participants reported their children having two or more developmental disabilities. The number of developmental disabilities was positively related to the severity of emotional and behavioral problems in children, which in turn explained general and parenting distress in parents.

CONCLUSIONS AND IMPLICATIONS

Given the heightened vulnerability to distress among parents of children with multiple developmental disabilities, psychological care should particularly target this population. Early identification and intervention strategies are also needed to detect children with multiple co-occurring developmental disabilities, which could potentially alleviate their emotional and behavioral problems and lessen the parenting burden.

Using self-reported vocational functioning measures to identify employed patients with impaired functional capacity in major depressive disorder

BACKGROUND

Patients with major depressive disorder (MDD) show impairments in cognitive functioning, including deficits on performance-based measures of functional capacity. A proportion of patients with MDD may achieve higher scores at baseline, and may not show a detectable response to treatment. How to identify these cases is the goal of this investigation.

METHODS

Retrospective analyses of data from the CONNECT study with vortioxetine were performed to determine whether the Work Limitations Questionnaire (WLQ) can be used to exclude very high-performing patients on the functional capacity outcome measure, University of California San Diego Performance-Based Skills Assessment (UPSA), in studies evaluating cognitive function impairment in MDD, to identify those with greater potential for treatment response. The post-hoc analyses included data on cognitive function assessed with a Digit Symbol Substitution Test (DSST) from vortioxetine-treated patients.

RESULTS

WLQ score >13 identified patients with greater impairments in UPSA-Brief (UPSA-B). Patients with WLQ scores >13, but not with scores ≤13, showed statistically significant improvements with vortioxetine treatment in UPSA-B and DSST compared with placebo.

LIMITATIONS

Study limitations include small sample size and use of post-hoc analyses. The generalizability of this analysis is limited to working patients with MDD.

CONCLUSIONS

The WLQ can be used to identify patients with MDD with high potential for treatment response in studies evaluating cognitive function impairment while excluding patients likely to achieve ceiling scores on UPSA. This approach helps identify higher performers on potential outcomes measures without biasing the study by requiring a specific UPSA cutoff score for eligible participants.

Four-year course of quality of life and obsessive-compulsive disorder

OBJECTIVE

Patients with obsessive compulsive disorder (OCD) have high disease burden. It is important to restore quality of life (QoL) in treatment, so that patients become able to live a fulfilling life. Little is known about the longitudinal course of QoL in patients with OCD, its association with remission from OCD, and about factors that contribute to an unfavourable course of QoL in remitting patients.

METHODS

Study on the 4-year course of QoL of patients with chronic (n = 144), intermittent (n = 22), and remitting OCD (n = 73) using longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA; complete data: n = 239; imputed data n = 382). The EuroQol five-dimensional questionnaire (EQ-5D) utility score was used to assess QoL. In patients with remitting OCD, we examined patient characteristics that contributed to an unfavourable course of QoL, including sociodemographics, OCD characteristics, psychiatric comorbidity, and personality traits.

RESULTS

Course of QoL was associated with course of OCD. QoL improved in those who remitted from OCD; however, even in these patients, QoL remained significantly below the population norms. The correlation between QoL and severity of OCD was only moderate: r = - 0.40 indicating that other factors besides OCD severity contribute to QoL. In remitters, more severe anxiety and depression symptoms were related to a lower QoL. Results were similar in complete and imputed data sets.

CONCLUSIONS

Remission from OCD is associated with improvement of QoL, but comorbid anxiety and depression symptoms hamper the improvement of QoL. QoL could be improved by reducing OCD symptoms in patients with OCD and by treating comorbid anxiety and depression symptoms in remitting patients.

Categorical improvement in functional impairment in depressed patients treated with desvenlafaxine

OBJECTIVE

This post-hoc pooled analysis evaluated categorical change in functional impairment in patients with major depressive disorder (MDD) treated with desvenlafaxine versus placebo and examined whether early improvement in functioning predicted functional outcomes at study endpoint.

METHODS

Data were pooled from eight randomized, double-blind, placebo-controlled studies of desvenlafaxine for the treatment of MDD, including adults who were randomly assigned to receive desvenlafaxine 50 or 100 mg/d or placebo (N=3,384). Shift tables were generated for categorical changes in functional impairment from baseline based on Sheehan Disability Scale (SDS) subscale scores. The categories were none/mild (0-3), moderate (4-6), and marked/extreme (7-10). Treatment comparisons for prespecified shifts of interest and predictive value of week 2 or 4 improvement in SDS subscale scores for functional outcome at week 8 were assessed using logistic regression.

RESULTS

Greater proportions of patients receiving desvenlafaxine 50 and 100 mg achieved improvement from baseline to week 8 for each prespecified shift endpoint versus placebo (all p ≤ 0.02). Early improvement in SDS subscale scores was a statistically significant predictor of functional outcome at week 8, both overall and for each treatment group (all p&lt;0.0001).

CONCLUSIONS

Treatment with desvenlafaxine 50 or 100 mg/d led to significantly greater categorical improvement in functional impairment versus placebo, and improvement in SDS subscale scores significantly predicted functional outcome. Monitoring patient progress early in the course of antidepressant treatment using a functional assessment such as the SDS may help clinicians determine whether or not treatment adjustments are needed.

Do Personality Traits Predict Functional Impairment and Quality of Life in Adult ADHD? A Controlled Study

OBJECTIVE

To examine the association of personality traits and characteristics on quality of life and functioning in adults with ADHD.

METHOD

Participants were adults with ( n = 206) and without ADHD ( n = 123) who completed the Temperament and Character Inventory (TCI), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and the Social Adjustment Scale-Self-Report (SAS-SR). Participants also provided information on academic, motor vehicle operation, legal, social, familial, and occupational functioning. Outcomes were examined using stepwise linear regression, logistic regression (for binary outcomes), and negative binomial regression (for count outcomes) controlling for ADHD symptoms, psychiatric comorbidity, and executive dysfunction.

RESULTS

Adults with ADHD significantly differed from controls across nearly all TCI personality domains. On average, adults with ADHD endorsed more novelty seeking, harm avoidance, and self-transcendence, and less reward dependence, persistence, self-directedness, and cooperativeness. Personality traits and characteristics, especially self-directedness, significantly predicted functional impairments even after controlling for ADHD symptoms, executive function deficits, and current psychiatric comorbidities.

CONCLUSION

In adults with ADHD, personality traits exert unique associations on quality of life and functional impairment across major life domains, beyond the relations expected of and associated with ADHD symptoms and other associated psychiatric conditions and cognitive vulnerabilities. Addressing personality traits in adults with ADHD may lead to improvements in quality of life and reductions in functional impairment.

Do baseline WAIS-III subtests predict treatment outcomes for depressed inpatients receiving fluoxetine?

This study aimed to determine whether baseline WAIS-III subtests could be associated with treatment outcomes for patients with major depressive disorder (MDD) receiving a 6-week fluoxetine treatment. A total of 131 acutely ill MDD inpatients were enrolled to receive 20 mg of fluoxetine daily for 6 weeks. Eight WAIS-III subtests were administered at baseline. Symptom severity and functional impairment were assessed at baseline, and again at weeks 1, 2, 3, 4, and 6 using the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Modified Work and Social Adjustment Scale (MWSAS), respectively. The generalized estimating equations method was used to analyze the influence of potential predictors over time on the HAMD-17 and MWSAS, after adjusting for covariates. Of the 131 participants, 104 (79.4%) who completed 8 WAIS-III subtests at baseline and had at least one post-baseline assessment were included in the analysis. Patients with lower forward digit span scores were more likely to have poor treatment outcomes, both measured by HAMD-17, and by MWSAS. Forward digit span may be clinically useful in identifying MDD patients with greater treatment difficulty in symptoms and functioning. Other neurocognitive tests to predict treatment outcome require further exploration.

The impact of their role on telephone crisis support workers' psychological wellbeing and functioning: Quantitative findings from a mixed methods investigation

Research suggests that frequent empathic engagement with others in distress places helpers in registered professional roles (e.g. medical practitioners, psychologists) at risk of functional impairment related to symptoms of psychological distress, including the delivery of sub-optimal care to patients. Preliminary research suggests that telephone crisis support workers may also be impacted in a similar way. This repeated measures study is the first known research to examine telephone crisis support workers’ functional impairment related to symptoms of psychological distress before and after speaking with callers in crisis. A representative sample of telephone crisis support workers from Lifeline Australia participated by completing three surveys: 1) directly before; 2) directly after; and 3) one week after completing a shift on the national crisis line. Surveys included standardised measures of functional impairment, psychological distress, lived experience of mental health issues and suicide, motivations for volunteering, coping strategies and help-seeking. Categorical items were used to assess personal and shift-related factors. Repeated measures analyses of variance were used to identify changes in symptoms of psychological distress and impairment across time points. Structural equation modelling was used to test relationships within a hypothesised model of impairment. A significant proportion of participants reported functional impairment related to symptoms of psychological distress. Significant differences in functional impairment and symptoms of psychological distress were detected, and were associated with different mechanisms, across time points. An important outcome of this study is empirically-supported models which explain how telephone crisis support workers come to experience functional impairment in relation to their TCS role, as well as other work/study, home/family and social/leisure activities. Results warrant the deliberate development and/or modification of existing service strategies to optimise telephone crisis support workers’ psychological wellbeing and functioning, including by structuring the work environment and emphasising certain messages during training and supervision.

A Subgroup Analysis of the Impact of Vortioxetine on Functional Capacity, as Measured by UPSA, in Patients with Major Depressive Disorder and Subjective Cognitive Dysfunction

BACKGROUND

We evaluated vortioxetine's effects on functional capacity in demographic and clinical subgroups of patients with major depressive disorder.

METHODS

This was an exploratory analysis of the CONNECT study (NCT01564862) that evaluated changes in functional capacity using University of California San Diego Performance-based Skills Assessment data, categorized by sex, age, education, employment status, and baseline disease severity (Montgomery-Åsberg Depression Rating Scale, Clinical Global Impressions-Severity of Illness).

RESULTS

Greater changes in University of California San Diego Performance-based Skills Assessment composite scores were observed with vortioxetine vs placebo in specific subgroups: males (∆+3.2), females (∆+2.9), 45-54 or ≥55 years (∆+5.6, ∆+3.4), working (∆+2.8), high school or greater education (∆+2.7, ∆+2.8), disease severity (Montgomery-Åsberg Depression Rating Scale, <30, ∆+3.5; ≥30, ∆+2.5; Clinical Global Impressions-Severity of Illness ≤4, ∆+2.8; >4, ∆+3.0), major depressive episodes (≤2, >2 [∆+2.7,+3.3]), and episode duration (≤22, >22 weeks [∆+3.7,+2.4]).

CONCLUSIONS

Our findings support the need for additional studies to assess whether vortioxetine improves functional capacity within specific patient subgroups.

CLINICAL TRIAL REGISTRY

clinicaltrials.gov: NCT01564862.

Vortioxetine improves symptomatic and functional outcomes in major depressive disorder: A novel dual outcome measure in depressive disorders

BACKGROUND

With symptomatic remission and functional recovery as the overarching therapeutic objectives of antidepressant therapy, composite endpoint measures that conjointly consider both aspects of treatment are needed. This analysis evaluated the combined effect of vortioxetine on depressive symptoms and functional capacity in adults with MDD.

METHODS

NCT01564862, a multinational, double-blind, placebo-controlled, duloxetine-referenced study, conducted between April 2012 and February 2014, in 602 adult outpatients (18-65 years) with moderate-to-severe MDD (Montgomery-Åsberg Depression Rating Scale (MADRS) ≥ 26), a major depressive episode of ≥ 3 months' duration, and self-reported cognitive symptoms were randomized to once-daily vortioxetine (10 or 20mg), duloxetine (60mg), or placebo for 8 weeks. Assessments included the University of California San Diego Performance-based Skills Assessment (UPSA) and the MADRS. Two versions of UPSA were utilized; UPSA ‒Validation of Intermediate Measures and UPSA Brief form. An aligned UPSA-B (communication and finance items) was examined for sensitivity analysis. Efficacy was analyzed versus placebo according to the dual response (change from baseline in UPSA ≥ 7 and ≥ 9 and reduction in MADRS total score from baseline ≥ 50%).

RESULTS

Significantly more vortioxetine-treated patients were classified as dual responders for change in MADRS total score and UPSA score of ≥ 7 (clinically important difference [CID]) (27.4% vs 14.5%; P = 0.004), and change above CID (≥ 9) (23.4% vs 13.9%; P = 0.025). Duloxetine did not differ significantly from placebo for these dual response criteria. Sensitivity analysis using the aligned UPSA-B confirmed these results for vortioxetine.

LIMITATIONS

An exploratory analysis of a new dual outcome measure in patients with MDD.

CONCLUSIONS

Vortioxetine, but not duloxetine, demonstrated a robust combined effect on depressive symptoms and functional capacity in patients with MDD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01564862; European Clinical Trials Database [EudraCT] Number 2011-005298-22.

A Systematic Review of the Measurement of Function in Late-Life Depression

Recovery of everyday premorbid function is a primary goal in the treatment of depression. Measurement of function is an important part of achieving this goal. A multitude of scales have been used to measure function in depression, reflecting the complex, multifaceted nature of functioning. Currently, however, there are no evidence-based guidelines to assist the researcher or clinician in deciding which instruments are best suited to measure function in late-life depression (LLD). Thus, the aims of this study are to 1) systematically review and identify the instrumental activities of daily living and social functioning assessment instruments used in the LLD literature; 2) identify and appraise the measurement properties of these instruments; and 3) suggest factors for LLD researchers and clinicians to consider when selecting functional assessment instruments and make pertinent recommendations. We performed a systematic review of MEDLINE and CINAHL to identify studies that i) incorporated subjects aged 60 years and older with a depressive disorder, and ii) measured instrumental activities of daily living and/or social functioning. Our search yielded 21 functional assessment instruments. Only two of these instruments, the 36-Item Short Form Survey and the Performance Assessment of Self-Care Skills, have formal validation data in LLD. Four additional instruments, although not formally validated, have relevant data regarding their measurement properties. The primary finding of this study is that very few functional assessment instruments have been validated in LLD, and the available measurement property data are mixed; there is a need for further instrument validation in late-life depression. With this caveat in mind, we provide evidence-based suggestions for researchers and clinicians assessing functioning in LLD patients.

Assessment and Management of Cognitive and Psychosocial Dysfunctions in Patients With Major Depressive Disorder: A Clinical Review

Background: Full functional recovery is defined as a state in which patients are again able to enjoy their usual activities, return to work, and take care of themselves, and it should represent the end goal of treatment in patients with major depressive disorder (MDD). Patients with MDD report many unmet needs, including residual cognitive symptoms, lack of improvement in psychosocial functioning and life satisfaction, even during mood symptom remission. In this paper, we aim to: (a) identify the available assessment tools for evaluating cognitive and psychosocial functioning in patients with MDD; (b) provide an overview of therapeutic options that can improve full functional recovery in MDD also by improving cognitive symptoms. Methods: The relevant databases MEDLINE, ISI Web of Knowledge - Web of Science Index, Cochrane Reviews Library and PsychoINFO were searched for identifying papers on validated tools for the assessment of cognitive and personal functioning in patients with MDD. Results: New assessment tools (such as the THINC-it TOOL, the COBRA, the SCIP-D, and the UPSA-D) have been developed for evaluating the cognitive dysfunction in MDD patients. Adopting these tools in the clinical routine practice is useful to evaluate the improvement in cognitive functioning and, therefore, the achievement of full functioning recovery. The optimal management of patients with MDD include the combination of pharmacological compounds and psychosocial interventions for achieving full functional recovery in patients with MDD. Conclusions: Full functional recovery must be the target of any treatment programme for patients with MDD. In order to achieve this goal, it is necessary to develop personalized treatment and integrate psychosocial and psychopharmacological interventions.

ECT Has Greater Efficacy Than Fluoxetine in Alleviating the Burden of Illness for Patients with Major Depressive Disorder: A Taiwanese Pooled Analysis

BACKGROUND

The burden of major depressive disorder includes suffering due to symptom severity, functional impairment, and quality of life deficits. The aim of this study was to compare the differences between electroconvulsive therapy and pharmacotherapy in reducing such burdens.

METHODS

This was a pooled analysis study including 2 open-label trials for major depressive disorder inpatients receiving either standard bitemporal and modified electroconvulsive therapy with a maximum of 12 sessions or 20 mg/d of fluoxetine for 6 weeks. Symptom severity, functioning, and quality of life were assessed using the 17-item Hamilton Rating Scale for Depression, the Modified Work and Social Adjustment Scale, and SF-36. Side effects following treatment, including subjective memory impairment, nausea/vomiting, and headache, were recorded. The differences between these 2 groups in 17-item Hamilton Rating Scale for Depression, Modified Work and Social Adjustment Scale, quality of life, side effects, and time to response (at least a 50% reduction of 17-item Hamilton Rating Scale for Depression) and remission (17-item Hamilton Rating Scale for Depression ≤7) following treatment were analyzed.

RESULTS

Electroconvulsive therapy (n=116) showed a significantly greater reduction in 17-item Hamilton Rating Scale for Depression, Modified Work and Social Adjustment Scale, and quality of life deficits and had significantly shorter time to response/remission than fluoxetine (n=126). However, the electroconvulsive therapy group was more likely to experience subjective memory impairment and headache.

CONCLUSIONS

Compared with fluoxetine, electroconvulsive therapy was more effective in alleviating the burden of major depressive disorder and had a substantially increased speed of response/remission in the acute phase. Increased education and information about electroconvulsive therapy for clinicians, patients, and their families and the general public is warranted.

Applicability of the Chinese version of the Personal and Social Performance scale in patients with severe mental disorders

INTRODUCTION

This study was designed to determine the reliability and validity of the Chinese version of the Personal and Social Performance scale (PSP-CHN) and assess the applicability of using the PSP-CHN in patients with severe mental disorders.

METHODS

A total of 285 outpatients with severe mental disorders, 220 with schizophrenia and 65 with major depressive disorder, were enrolled into the study. Both diagnoses were made using the DSM-IV. All the patients were assessed with the PSP-CHN, the GAF, and the CGI-S. In addition, the PANSS and the MADRS were used to assess the patients with schizophrenia and major depressive disorder, respectively.

RESULTS

The PSP-CHN showed good internal consistency (Cronbach α = 0.839, n = 285), high interrater reliability for total scores (intraclass correlation coefficient, ICC = 0.865, n = 48), and good test-retest reliability (ICC = 0.892, n = 130). The PSP-CHN total score showed a statistically significant positive correlation with the GAF score (r = 0.927, P < .01, n = 285), as well as a significant negative correlation with the CGI-S total score (r = -0.793, P < .01, n = 285), the PANSS total score (r = -0.694, P < .01, n = 220), and the MADRS total score (r = -0.721, P < .01, n = 65).

DISCUSSION

We were able to demonstrate that the PSP-CHN is a reliable and valid measurement tool to assess the personal and social functioning in patients with severe mental disorders.

Functional Recovery in Major Depressive Disorder: Providing Early Optimal Treatment for the Individual Patient

Major depressive disorder is an often chronic and recurring illness. Left untreated, major depressive disorder may result in progressive alterations in brain morphometry and circuit function. Recent findings, however, suggest that pharmacotherapy may halt and possibly reverse those effects. These findings, together with evidence that a delay in treatment is associated with poorer clinical outcomes, underscore the urgency of rapidly treating depression to full recovery. Early optimized treatment, using measurement-based care and customizing treatment to the individual patient, may afford the best possible outcomes for each patient. The aim of this article is to present recommendations for using a patient-centered approach to rapidly provide optimal pharmacological treatment to patients with major depressive disorder. Offering major depressive disorder treatment determined by individual patient characteristics (e.g., predominant symptoms, medical history, comorbidities), patient preferences and expectations, and, critically, their own definition of wellness provides the best opportunity for full functional recovery.

The Relationship between Symptom Relief and Psychosocial Functional Improvement during Acute Electroconvulsive Therapy for Patients with Major Depressive Disorder

Background

We aimed to compare the degree of symptom relief to psychosocial functional (abbreviated as "functional") improvement and explore the relationships between symptom relief and functional improvement during acute electroconvulsive therapy for patients with major depressive disorder.

Methods

Major depressive disorder inpatients (n=130) requiring electroconvulsive therapy were recruited. Electroconvulsive therapy was generally performed for a maximum of 12 treatments. Symptom severity, using the 17-item Hamilton Depression Rating Scale, and psychosocial functioning (abbreviated as "functioning"), using the Modified Work and Social Adjustment Scale, were assessed before electroconvulsive therapy, after every 3 electroconvulsive therapy treatments, and after the final electroconvulsive therapy. Both 17-item Hamilton Depression Rating Scale and Modified Work and Social Adjustment Scale scores were converted to T-score units to compare the degrees of changes between depressive symptoms and functioning after electroconvulsive therapy. Structural equation modeling was used to test the relationships between 17-item Hamilton Depression Rating Scale and Modified Work and Social Adjustment Scale during acute electroconvulsive therapy.

Results

One hundred sixteen patients who completed at least the first 3 electroconvulsive therapy treatments entered the analysis. Reduction of 17-item Hamilton Depression Rating Scale T-scores was significantly greater than that of Modified Work and Social Adjustment Scale T-scores at assessments 2, 3, 4, and 5. The model analyzed by structural equation modeling satisfied all indices of goodness-of-fit (chi-square = 32.882, P =.107, TLI = 0.92, CFI = 0.984, RMSEA = 0.057). The 17-item Hamilton Depression Rating Scale change did not predict subsequent Modified Work and Social Adjustment Scale change.

Conclusions

Functioning improved less than depressive symptoms during acute electroconvulsive therapy. Symptom reduction did not predict subsequent functional improvement. Depressive symptoms and functional impairment are distinct domains and should be assessed independently to accurately reflect the effectiveness of electroconvulsive therapy.

Restoring function in major depressive disorder: A systematic review

BACKGROUND

Functional impairment contributes to significant disability and economic burden in major depressive disorder (MDD). Treatment response is measured by improvement in depressive symptoms, but functional improvement often lags behind symptomatic improvement. Residual deficits are associated with relapse of depressive symptoms.

METHODS

A literature search was conducted using the following terms: "major depressive disorder," "functional impairment," "functional outcomes," "recovery of function," "treatment outcome," "outcome assessment," "social functioning," "presenteeism," "absenteeism," "psychiatric status rating scales," and "quality of life." Search limits included publication date (January 1, 1995 to August 31, 2016), English language, and human clinical trials. Controlled, acute-phase, nonrecurrent MDD treatment studies in adults were included if a functional outcome was measured at baseline and endpoint.

RESULTS

The qualitative analysis included 35 controlled studies. The Sheehan Disability Scale was the most commonly used functional assessment. Antidepressant treatments significantly improved functional outcomes. Early treatment response predicted functional improvement, while baseline disease severity did not.

LIMITATIONS

Clinical studies utilized various methodologies and assessments for functional impairment, and were not standardized or adequately powered.

CONCLUSIONS

The lack of synchronicity between symptomatic and functional improvement highlights an unmet need for MDD. Treatment guided by routine monitoring of symptoms and functionality may minimize residual functional impairments.

Determination of a clinically important difference and definition of a responder threshold for the UCSD performance-based skills assessment (UPSA) in patients with major depressive disorder

BACKGROUND

This article reports an evaluation of the psychometric properties and clinically important difference (CID) threshold of the UCSD Performance-Based Skills Assessment (UPSA) in major depressive disorder (MDD), using data from a large-scale study of the effects of vortioxetine on cognitive functioning and functional capacity in MDD patients.

METHODS

Adults with moderate-to-severe recurrent MDD and self-reported cognitive dysfunction were randomized to 8 weeks of double-blind treatment with vortioxetine 10/20mg QD (flexible), duloxetine 60mg QD, or placebo. Pearson correlation coefficients were calculated between UPSA composite score and demographic/disease characteristics at baseline to examine construct validity. Two methods (distribution-based and anchor-based) were used to establish a CID threshold.

RESULTS

A total of 602 patients were randomized; 528 comprised the full analysis set. For the entire sample mean UPSA composite scores were 77.8 at baseline and 83.9 at week 8 (mean change, +6.1). As hypothesized, at baseline, the UPSA composite score correlated with cognitive functioning (Digit Symbol Substitution Test: r=0.36, P<0.001) and workplace productivity (Work Limitations Questionnaire: r=-0.17, P=0.008), but not depressive symptoms (Montgomery-Åsberg Depression Rating Scale: r=0.02, P=0.707) or subjective cognitive dysfunction (Perceived Deficits Questionnaire: r=-0.02, P=0.698).

LIMITATIONS

Two versions of the UPSA were used and no inclusion/exclusion criteria were based on the UPSA.

CONCLUSIONS

These results support the construct validity of UPSA for assessing functional capacity independent of mood symptoms. The estimated CID for changes in UPSA scores was quite consistent at +6.4 points and +6.7 based on distribution-based and anchor-based methods, respectively.

Effects of levomilnacipran extended-release on major depressive disorder patients with cognitive impairments: post-hoc analysis of a phase III study

Performance-based cognitive data were collected using the Cognitive Drug Research System in a study of levomilnacipran extended-release (ER) 40-120 mg/day (NCT01034462) in adults with major depressive disorder. These data were analyzed post-hoc to explore the relationship between cognitive measures, depression symptoms (Montgomery-Åsberg Depression Rating Scale, MADRS), and self-reported psychosocial functioning (Sheehan Disability Scale; SDS). Changes from baseline were analyzed in the intent-to-treat population and subgroups with impaired attention, as indicated by baseline Cognitive Drug Research System scores for Power of Attention and Continuity of Attention. Path analyses evaluated the direct and indirect effects of levomilnacipran ER on SDS total score change. Significantly greater improvements were observed for levomilnacipran ER versus placebo for Power of Attention, Continuity of Attention, MADRS, and SDS score changes; the mean differences were larger in the impaired subgroups than in the overall intent-to-treat population. Path analyses showed that the majority of SDS total score improvement (≥50%) was attributable to an indirect treatment effect through MADRS total score change; some direct effect of levomilnacipran ER on SDS total score improvement was also observed. In adults with major depressive disorder, levomilnacipran ER effectively improved measures of depression and cognition, which contributed toward reductions in self-reported functional impairment.

The effect of vortioxetine on overall patient functioning in patients with major depressive disorder

BACKGROUND

The objectives of this meta-analysis of data from randomized, placebo-controlled studies were to assess the effect of vortioxetine on overall functioning (primary) and functional remission (secondary) using the Sheehan Disability Scale (SDS) in adults with major depressive disorder (MDD).

METHODS

Data from nine short-term (6/8 weeks) pivotal studies that included patient functioning assessments were included in this random-effects meta-analysis, which used aggregated study-level data for all therapeutic vortioxetine doses and a mixed-effect model for repeated measures using the full analysis set.

RESULTS

A total of 4,216 patients received ≥1 dose of study treatment (1,522 placebo, 2,694 vortioxetine 5-20 mg/day). At study end, the meta-analysis showed improvement for vortioxetine versus placebo (n = 911) in SDS total score (vortioxetine 5 mg, n = 564, change from baseline versus placebo [Δ] -0.24, p = NS; 10 mg, n = 445, Δ -1.68, p ≤ .001; 15 mg, n = 204, Δ -0.91, p = NS; 20 mg, n = 340, Δ -1.94, p ≤ .01). Functional remission (SDS total score ≤6) was observed with vortioxetine 10 mg (n = 170/573; odds ratio [OR] relative to placebo 1.7, p < .001) and 20 mg (n = 144/447; OR 1.6, p < .05), but not 5 mg (n = 207/757; OR 1.1, p = NS) or 15 mg (n = 92/295; OR 1.3, p = NS).

CONCLUSION

Vortioxetine 5-20 mg for 6/8 weeks improved overall patient functioning in patients with MDD. Relative to placebo, vortioxetine 10 and 20 mg demonstrated significant improvement in SDS total score and functional remission.

Effects of levomilnacipran extended-release on motivation/energy and functioning in adults with major depressive disorder

The objective of this post-hoc analysis was to investigate the relationship between motivation/energy and functional impairment in patients with major depressive disorder (MDD). Data were taken from a phase 3 trial of levomilnacipran extended-release (ER) in adults with MDD (NCT01034462; N=429) that used the 18-item Motivation and Energy Inventory (MEI) to assess motivation/energy. Two subgroups with lower and higher motivation/energy were defined using baseline MEI total scores (≤28 and >28, respectively). Change from baseline in the Sheehan Disability Scale (SDS) total score was analyzed in the intent-to-treat (ITT) population and both subgroups. Path analyses were carried out in the ITT population and a lower MEI subgroup to assess the direct and indirect effects of levomilnacipran ER on SDS total score change. In the ITT population and the lower MEI subgroup, significant differences were found between levomilnacipran ER and placebo for changes in the SDS total score (-2.6 and -3.9, both P<0.01), but not in the higher MEI subgroup. The indirect effect of levomilnacipran ER on SDS total score improvement, as mediated by MEI total score change, was 79.9% in the lower MEI subgroup and 67.2% in the ITT population. Levomilnacipran ER was previously shown to improve motivation/energy in adults with MDD. The current analysis indicates that improvements in functional impairment were considerably mediated by improvements in motivation/energy, particularly in patients with lower motivation/energy at baseline.

Correlates of Disability in Asian Patients With Major Depressive Disorder

PURPOSE

To examine correlates of disability in Asian patients with major depressive disorder (MDD).

DESIGN AND METHODS

Participants were outpatients with DSM-IV MDD. Global disability and three disability domains (i.e., work/school, social life/leisure, and family/home life) were key outcomes. Several socio-demographic and clinical characteristics were determined for their associations with disability.

FINDINGS

The sample was 493 MDD patients. Apart from the number of hospitalizations, the global disability was significantly associated with depression severity, fatigue, physical health, and mental health. Several clinical but only few socio-demographic characteristics associated with the other three disability domains were similar.

PRACTICE IMPLICATIONS

Disability among Asian patients with MDD correlates with the severity of psychiatric symptoms and the hospitalizations due to depression. Socio-demographic characteristics have little impact on the overall disability.

The efficacy of levomilnacipran ER across symptoms of major depressive disorder: a post hoc analysis of 5 randomized, double-blind, placebo-controlled trials

OBJECTIVE

A post hoc analysis evaluated the effects of levomilnacipran ER on individual symptoms and symptom domains in adults with major depressive disorder (MDD).

METHODS

Data were pooled from 5 Phase III trials comprising 2598 patients. Effects on depression symptoms were analyzed based on change from baseline in individual Montgomery-Åsberg Depression Rating Scale (MADRS) item scores. A1dditional evaluations included resolution of individual symptoms (defined as a MADRS item score ≤1 at end of treatment) and concurrent resolution of all 10 MADRS items, all MADRS6 subscale items, and all items included in different symptom clusters (Dysphoria, Retardation, Vegetative Symptoms, Anhedonia).

RESULTS

Significantly greater mean improvements were found on all MADRS items except Reduced Appetite with levomilnacipran ER treatment compared with placebo. Resolution of individual symptoms occurred more frequently with levomilnacipran ER than placebo for each MADRS item (all P<.05), with odds ratios (ORs) ranging from 1.26 to 1.75; resolution of all 10 items was also greater with levomilnacipran ER (OR=1.57; P=.0051). Significant results were found for the MADRS6 subscale (OR=1.73; P<.0001) and each symptom cluster (OR range, 1.39 [Vegetative Symptoms] to 1.84 [Retardation]; all clusters, P<.01).

CONCLUSION

Adult MDD patients treated with levomilnacipran ER improved across a range of depression symptoms and symptom domains.

IMPROVEMENTS IN PSYCHOSOCIAL FUNCTIONING AND HEALTH-RELATED QUALITY OF LIFE FOLLOWING EXERCISE AUGMENTATION IN PATIENTS WITH TREATMENT RESPONSE BUT NONREMITTED MAJOR DEPRESSIVE DISORDER: RESULTS FROM THE TREAD STUDY

BACKGROUND

Functional impairments often remain despite symptomatic improvement with antidepressant treatment, supporting the need for novel treatment approaches. The present study examined the extent to which exercise augmentation improved several domains of psychosocial functioning and quality of life (QoL) among depressed participants.

METHODS

Data were collected from 122 partial responders to antidepressant medication. Participants were randomized to either high- (16 kcal/kg of weight/week [KKW]) or low-dose (4-KKW) exercise. Participants completed a combination of supervised and home-based exercise for 12 weeks. The Short-Form Health Survey, Work and Social Adjustment Scale, Social Adjustment Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, and Satisfaction with Life Scale were collected at 6 and 12 weeks. Participants with data for at least one of the two follow-up time points (n = 106) were analyzed using a linear mixed model to assess change from baseline within groups and the difference between groups for each psychosocial outcome measure. All analyses controlled for covariates, including baseline depressive symptomatology.

RESULTS

Participants experienced significant improvements in functioning across tested domains, and generally fell within a healthy range of functioning on all measures at Weeks 6 and 12. Although no differences were found between exercise groups, improvements were observed across a variety of psychosocial and QoL domains, even in the low-dose exercise group.

CONCLUSIONS

These findings support exercise augmentation of antidepressant treatment as a viable intervention for treatment-resistant depression to improve function in addition to symptoms.

The Effects of Newer Antidepressants on Occupational Impairment in Major Depressive Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

A substantial proportion of the disease burden of major depressive disorder (MDD) results from impairments in occupational functioning, including disability and reduced productivity. Accumulating evidence suggests that antidepressants can improve functional as well as symptomatic outcomes in patients with MDD. We examined the treatment effects of newer antidepressants on occupational impairment in MDD, based on a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched MEDLINE, EMBASE, and ClinicalTrials.gov for the period 1 January 1992 to 15 June 2015 to identify RCTs of newer antidepressants (excluding tricyclic antidepressants and monoamine oxidase inhibitors), with or without a placebo condition, that included a validated measure of occupational functioning in patients with MDD. Abstracts were scanned for eligibility by two independent reviewers and investigators of unpublished studies were contacted to obtain data. Study data were extracted and double-entered for accuracy. We selected the Sheehan Disability Scale Work/School subscale (SDS-Work) for the meta-analysis because it was the most consistently used assessment of occupational impairment. Analysis employed a random-effects model.

RESULTS

The systematic review initially identified 42 RCTs but only 28 (67 %) had data on occupational outcomes that were published or obtained from investigators. The SDS-Work subscale was used in 25 of 28 trials; five other assessments of occupational functioning were used in seven trials. Data were synthesized from 17 placebo-controlled studies (n = 7031) that used the SDS-Work subscale. Antidepressants (n = 4722) were significantly superior to placebo (n = 2309) in improving SDS-Work scores at 8 weeks, with a mean difference of 0.73 [95 % confidence interval (CI) 0.60-0.86] and a standardized mean difference of 0.28 (95 % CI 0.23-0.33), representing small effects.

LIMITATIONS

Few included trials reported on the employment status of their samples, and most trials were of short-term treatment duration (8-12 weeks). Several RCTs that collected data on occupational outcomes were also excluded from the review and meta-analysis because their data were unpublished and unobtainable.

CONCLUSIONS

Our meta-analysis suggests that newer antidepressants have a small, positive impact on occupational impairment in the short-term, but the clinical significance of this impact is questionable. To improve assessment of this important outcome, future research studies should use more comprehensive measures of occupational functioning, productivity and impairment, and longer treatment durations.

Cognitive Deficits as a Mediator of Poor Occupational Function in Remitted Major Depressive Disorder Patients

Cognitive deficits in major depressive disorder (MDD) patients have been described in numerous studies. However, few reports have aimed to describe cognitive deficits in the remitted state of MDD and the mediational effect of cognitive deficits on occupational outcome. The aim of the current review is to synthesize the literature on the mediating and moderating effects of specific domains of cognition on occupational impairment among people with remitted MDD. In addition, predictors of cognitive deficits found to be vocationally important will be examined. Upon examination of the extant literature, attention, executive function and verbal memory are areas of consistent impairment in remitted MDD patients. Cognitive domains shown to have considerable impact on vocational functioning include deficits in memory, attention, learning and executive function. Factors that adversely affect cognitive function related to occupational accommodation include higher age, late age at onset, residual depressive symptoms, history of melancholic/psychotic depression, and physical/psychiatric comorbidity, whereas higher levels of education showed a protective effect against cognitive deficit. Cognitive deficits are a principal mediator of occupational impairment in remitted MDD patients. Therapeutic interventions specifically targeting cognitive deficits in MDD are needed, even in the remitted state, to improve functional recovery, especially in patients who have a higher risk of cognitive deficit.

Functional Impairment and Changes in Depression Subtypes for Women in STAR*D: A Latent Transition Analysis

OBJECTIVE

To characterize the association between functional impairment and major depression subtypes at baseline and to characterize changes in subtypes by functional impairment level in women receiving citalopram in level 1 of the Sequenced Treatment Alternatives to Relieve Depression trial.

METHOD

Women who completed baseline and week 12 study visits were included. Items from the self-reported Quick Inventory of Depressive Symptomatology were used to define the latent depression subtypes. The Work and Social Adjustment Scale was used to classify baseline functional impairment. A latent transition analysis model provided estimates of the prevalence of subtype membership and transition probabilities by functional impairment level.

RESULTS

Of the 755 women included, 69% had major functional impairment at baseline. Regardless of functional impairment level, the subtypes were differentiated by depression severity, appetite changes, psychomotor disturbances, and insomnia. Sixty-seven percent of women with normal/significant functional impairment and 60% of women with major impairment were likely to transition to a symptom resolution subtype at week 12. Women with baseline major impairment who were in the severe with psychomotor agitation subtype at the beginning of the study were least likely to transition to the symptom resolution subtype (4% chance).

CONCLUSIONS

Functional impairment level was related to both the baseline depression subtype and the likelihood of moving to a different subtype. These results underscore the need to incorporate not only depression symptoms but also functioning in the assessment and treatment of depression.

The relationship between symptom relief and functional improvement during acute fluoxetine treatment for patients with major depressive disorder

BACKGROUND

The purpose of this study was to compare the rate of symptom relief to functional improvement and examine the relationships between symptom relief and functional improvement during the acute phase of treatment.

METHODS

A total of 131 acutely ill inpatients with major depressive disorder were enrolled to receive 20mg of fluoxetine daily for 6 weeks. Symptom severity, using the 17-item Hamilton Depression Rating Scale (HAMD-17), and functioning, using the Modified Work and Social Adjustment Scale (MWSAS), were measured regularly. The outcome measures were the HAMD-17 score and MWSAS score at weeks 1, 2, 3, 4, and 6. We compared the effect size and the reduction rate of HAMD-17 to those of MWSAS at week 1, 2, 3, 4, and 6. Structural equation modeling was used to examine relationships among the study variables.

RESULTS

Of the 131 participants, 126 had at least one post-baseline assessment at week 1 and were included in the analysis. The HAMD-17 had a larger effect size and reduction rate than the MWSAS at weeks 1, 2, 3, 4, and 6. Parsimonious model satisfied all indices of goodness-of-fit (Chi-Square/df=1.479, TLI=0.978, CFI=0.986, RMSEA=0.062) and had all paths with significant path coefficients. MWSAS at week 0 predicted HAMD-17 at week 1.

LIMITATION

This was an open-labeled study with small sample size.

CONCLUSION

Depressive symptoms improved more quickly than functioning during the acute phase of treatment. Depressive symptoms and functional impairment are distinct domains, and should be assessed independently.

Functional outcome in major psychiatric disorders and associated clinical and psychosocial variables: A potential cross-diagnostic phenotype for further genetic investigations?

OBJECTIVES

Functional outcome has recently become of interest for cross-diagnostic subphenotype approaches in psychiatric genetics. Therefore, it is crucial to know about clinical, demographic and psychosocial variables that correlate with long-term functioning. Unfortunately, there is a lack of studies that directly compare the importance of correlates for functional outcome between different disorders.

METHODS

Applying regression models to samples of patients with schizophrenia (SZ, n = 238), bipolar disorder (BD, n = 533) and major depressive disorder (MDD, n = 398), we compared the magnitude of association of potential correlates with functional outcome, measured by the Global Assessment of Functioning (GAF) score.

RESULTS

Shared correlates for worse functional outcome were poor premorbid functioning, insidious illness onset and poor premorbid work or social adjustment in all three disorders, and negative symptomatology in SZ and BD. Disorder-specific correlates for SZ were longer duration of illness, lower functioning during episodes and being life-time single, for BD substance abuse and suicidality, and for MDD premorbid unemployment and having a premorbid personality disorder.

CONCLUSIONS

We found different patterns of correlates for long-term functioning in SZ, BD and MDD. Knowledge of these patterns may improve the quality of genetic investigations focussing on functional outcome.

Displacement as a predictor of functional impairment in tsunami-exposed children

Thirty months after the Indian Ocean tsunami of 26 December 2004, thousands of families in Aceh Province, Indonesia, remained in temporary barracks while sanitation conditions and non-governmental organisation support deteriorated. This study sought to determine the factors associated with functional impairment in a sample of 138 displaced and non-displaced Acehnese children. Using multivariate linear regression models, it was found that displacement distance was a consistent predictor of impairment using the Brief Impairment Scale. Exposure to tsunami-related trauma markers was not significantly linked with impairment in the model. Paternal employment was a consistent protective factor for child functioning. These findings suggest that post-disaster displacement and the subsequent familial economic disruption are significant predictors of impaired functioning in children's daily activities. Post-disaster interventions should consider the disruption of familiar environments for families and children when relocating vulnerable populations to avoid deleterious impacts on children's functioning.

The effect of bupropion XL and escitalopram on memory and functional outcomes in adults with major depressive disorder: results from a randomized controlled trial

Decrements in cognitive function are a common feature of Major Depressive Disorder (MDD), and whether distinct classes of antidepressants differentially affect memory in these individuals has not been sufficiently evaluated. In this study we sought to determine the effect of escitalopram and bupropion XL on memory and psychosocial function. Forty-one individuals (18-50 years) with MDD were enrolled in an 8-week, double-blind, double-dummy, randomized controlled comparative trial of bupropion XL and escitalopram. Thirty-six participants completed pre and post memory assessments. Verbal, non-verbal and working memory were evaluated with a comprehensive neuropsychological battery. Psychosocial function was assessed with the Sheehan Disability Scale and Endicott Work Productivity Scale. Escitalopram and bupropion XL significantly improved immediate as well as delayed verbal and nonverbal memory, global function (all p≤0.001), and work productivity (p=0.045), with no significant between-group differences. Improvement in immediate verbal memory exerted a direct influence on improvement in global function (p=0.006). Treatment with either escitalopram or bupropion XL was associated with improvement in memory and psychosocial function in adults with MDD.