Predictors of response and remission in a naturalistic inpatient sample undergoing multimodal treatment for depression

Functional connectivity between the cerebellar vermis and cerebrum distinguishes early treatment response for major depressive episodes in adolescents

BACKGROUND

The absence of biomarkers for predicting treatment response in adolescent mood disorder calls for further research. The vermis, a component of the cerebellum, is involved in mood disorder pathophysiology and relates to clinical symptoms and treatment outcomes. We investigated vermis functional connectivity (FC) as an early marker for treatment response identification.

METHOD

One hundred thirty-two adolescents with mood disorders including major depressive disorder or bipolar disorder, were recruited, who were experiencing a major depressive episode. All adolescents underwent baseline and 2-week treatment resting-state MRI scans. Hamilton Rating Scale for Depression (HAMD) assessments were completed to assess the severity of symptoms. Patients were divided into treatment-responsive (≥50 % HAMD reduction, n = 75) and treatment-unresponsive subgroups (n = 57). Vermis FCs were compared between subgroups at baseline. And we compared the pre- and post-treatment FC differences within subgroups.

RESULT

Higher vermis-left temporal lobe FC in treatment-responsive group compared to treatment-unresponsive group at baseline. The FC value showed positive prognosis for the efficacy, with the area under the curve (AUC) of 0.760 (95 % confidence interval: 0.678-0.843, p < 0.001), suggesting higher vermis-temporal FC is benefit to improve treatment-response. Furthermore, post-treatment analysis showed significant increases in the vermis-right frontal lobe FC values between in all patients, suggesting that vermis-frontal FCs were independent of treatment-outcome.

LIMITATION

Sample size was relatively small, which may limit the generalizability of our results.

CONCLUSION

Our study revealed that the FC between the vermis and the cortex is not only associated with symptom alleviation but also predictive of treatment outcomes.

Treating depression in an outpatient setting: Predictors of patient response to bouldering psychotherapy, cognitive behavioural therapy or exercise alone

BACKGROUND

Bouldering psychotherapy (BPT) for depression has proven effective, but nothing is known about its potential predictors of response. This study should identify predictors of response to BPT, cognitive behavioural therapy (CBT) and an active control (home-based exercise programme; EP) using a literature-based model.

METHODS

In a multicentre randomised controlled trial, 233 outpatients were assigned to BPT, CBT or EP. Response (reduction of at least 46% on the Montgomery-Åsberg Depression Rating Scale [MADRS]) and remission (≤7 MADRS points) were defined as suggested by the literature. Predictors of response were identified twofold: (1) univariate analyses followed by logistic regression analyses in each group with all predictors yielding a univariate p-value <.20 and (2) a backward regression analysis with all potential predictors. Only variables that emerged as predictors in both types of analyses were interpreted.

RESULTS

There was a significantly greater proportion of responders (p = .035) in the BPT than in the EP. The chance of response in the BPT was higher for patients with a higher health-related quality of life. In the EP, response was higher for patients with lower interpersonal sensitivity, suffering from their first episode and living with a partner.

CONCLUSIONS

Response rates in BPT are similar to or even higher than in other outpatient psychotherapy group therapies. BPT and CBT are suitable for a wide range of patients, but patients with higher functionality could start with psychoeducation and exercise.

Integrated Module of Multidimensional Omics for Peripheral Biomarkers (iMORE) in patients with major depressive disorder: rationale and design of a prospective multicentre cohort study

INTRODUCTION

Major depressive disorder (MDD) represents a worldwide burden on healthcare and the response to antidepressants remains limited. Systems biology approaches have been used to explore the precision therapy. However, no reliable biomarker clinically exists for prognostic prediction at present. The objectives of the Integrated Module of Multidimensional Omics for Peripheral Biomarkers (iMORE) study are to predict the efficacy of antidepressants by integrating multidimensional omics and performing validation in a real-world setting. As secondary aims, a series of potential biomarkers are explored for biological subtypes.

METHODS AND ANALYSIS

iMore is an observational cohort study in patients with MDD with a multistage design in China. The study is performed by three mental health centres comprising an observation phase and a validation phase. A total of 200 patients with MDD and 100 healthy controls were enrolled. The protocol-specified antidepressants are selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Clinical visits (baseline, 4 and 8 weeks) include psychiatric rating scales for symptom assessment and biospecimen collection for multiomics analysis. Participants are divided into responders and non-responders based on treatment response (>50% reduction in Montgomery-Asberg Depression Rating Scale). Antidepressants' responses are predicted and biomarkers are explored using supervised learning approach by integration of metabolites, cytokines, gut microbiomes and immunophenotypic cells. The accuracy of the prediction models constructed is verified in an independent validation phase.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of Shanghai Mental Health Center (approval number 2020-87). All participants need to sign a written consent for the study entry. Study findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04518592.

Pharmacological treatment of major depressive disorder according to severity in psychiatric inpatients: results from the AMSP pharmacovigilance program from 2001-2017

The International Classification of Diseases (10^th Version) categorizes major depressive disorder (MDD) according to severity. Guidelines provide recommendations for the treatment of MDD according to severity. Aim of this study was to assess real-life utilization of psychotropic drugs based on severity of MDD in psychiatric inpatients. Drug utilization data from the program “Drug Safety in Psychiatry” (German: Arzneimittelsicherheit in der Psychiatrie, AMSP) were analyzed according to the severity of MDD. From 2001 to 2017, 43,868 psychiatric inpatients with MDD were treated in participating hospitals. Most patients were treated with ≥ 1 antidepressant drug (ADD; 85.8% of patients with moderate MDD, 89.8% of patients with severe MDD, and 87.9% of patients with psychotic MDD). More severely depressed patients were more often treated with selective serotonin–norepinephrine reuptake inhibitors and mirtazapine and less often with selective serotonin reuptake inhibitors (p < 0.001 each). Use of antipsychotic drugs (APDs), especially second-generation APDs, increased significantly with severity (37.0%, 47.9%, 84.1%; p < 0.001 each). APD + ADD was the most used combination (32.8%, 43.6%, 74.4%), followed by two ADDs (26.3%, 29.3%, 24.9%). Use of lithium was minimal (3.3%, 6.1% ,7.1%). The number of psychotropic drugs increased with severity of MDD—patients with psychotic MDD had the highest utilization of psychotropic drugs (93.4%, 96.5%, 98.7%; p < 0.001). ADD monotherapy was observed to a lesser extent, even in patients with non-severe MDD (23.2%, 17.1%, 4.4%). Findings reveal substantial discrepancies between guideline recommendations and real-life drug utilization, indicating that guidelines may insufficiently consider clinical needs within the psychiatric inpatient setting.

Social withdrawal as a trans-diagnostic predictor of short-term remission: a meta-analysis of five clinical cohorts

Social withdrawal is an early manifestation of several neuropsychiatric disorders, and it is characterised by a gradual disengagement from social interactions, potentially leading to complete isolation. This study investigated the association between social withdrawal at baseline and short-term symptom remission in five independent cohorts, including patients with major depressive disorder (MDD), bipolar spectrum disorders, and schizophrenia. Measures of social withdrawal were derived in each study, and clinical remission was estimated based on the psychopathological severity assessed after short-term psychopharmacological treatment (12 weeks). Logistic regression was performed in each sample, adjusting for age and baseline psychopathological severity residualised for social withdrawal. Results were then meta-analysed across samples within a random-effect framework. A total of 4461 patients were included in the analyses (3195 patients with MDD, 655 with bipolar spectrum disorders and 611 with schizophrenia). The meta-analysis showed that higher baseline levels of social withdrawal were associated with a decreased likelihood of short-term remission (ORadj = 0.67, 95% CI, 0.58-0.79, P = 5.28 × 10-7), with the strongest effect in patients with schizophrenia. Overall, our study highlighted the need to address social withdrawal in the early phases of the disease to promote symptom remission in patients with major psychiatric disorders. Understanding the neurobiology underlying social withdrawal may aid the development of medications that can specifically reverse social impairment, thereby fostering clinical remission.

Early-onset late-life depression: Association with body mass index, obesity, and treatment response

Early-onset (EOD) and late-onset (LOD) late-life depression might differ in etiology, clinical features, and treatment response. While EOD is more frequently associated with a family history of affective disorders and personality aspects, LOD is thought to be more strongly driven by acquired cerebrovascular risk factors associated with vascular pathology, executive dysfunction, and poor treatment response. However, in a systematic review, EOD and LOD only differed in the frequency of affective disorders in the family history. We compared EOD versus LOD using medical records. In this retrospective chart review, elderly depressed patients (N = 108; mean age: 69.0 ± 7.2 years) were characterized by sociodemographic, psychiatric, and somatic variables and divided according to age-at-onset (cut-off: 60 years): EOD (N = 67, mean age-at-onset: 40.2 ± 13.6 years) and LOD (N = 41, 67.5 ± 6.3 years). A family history of affective disorders was more common in EOD than LOD patients (49.2% vs. 19.5%). EOD patients had a higher body mass index (mean: 27.0 kg/m² vs. 23.1 kg/m²) and were more often obese compared with LOD patients (20% vs. 0%). There were fewer treatment responders in the EOD group than in the LOD group on trend level significance (46.3% vs. 63.4%). Higher frequency of affective disorders in the family history is compatible with a greater genetic risk of EOD. The larger metabolic burden of EOD might stem from the longer duration of depressive illness.

•

We compared clinical characteristics and treatment response of elderly depressed patients with early-onset vs. late-onset.

•

We found a higher frequency of affective disorders in the family history of early-onset patients.

•

Early-onset patients had a higher body mass index and were more often obese.

•

There were fewer treatment responders in the EOD group than in the LOD group on trend level significance.

•

Our findings point to an increased obesity risk in EOD along with poorer treatment outcome.

Predictors for successful psychotherapy: Does migration status matter?

Background

We investigated, if migration status, and additional sociodemographic and clinical factors, are associated with somatization and depressiveness at admission and with remission after inpatient psychotherapy.

Methods

Multiple linear and binary logistic regression analyses were used to identify predictors for severity of somatoform and depressive symptoms at admission of inpatient psychotherapy (T0), and for remission after inpatient psychotherapy (T1). We tested the association between symptoms concerning somatization (PHQ-15: Patient-Health-Questionnaire Somatization Module) and depression (PHQ-9: Patient-Health-Questionnaire Depression Module) and several sociodemographic and clinical factors in 263 patients at admission. For remission after treatment, we additionally included severity of symptoms at admission, number of diagnoses and duration of treatment in the regression models. Remission after treatment was defined as response plus a post value of less than 10 points in the respective questionnaire. Clinical relevance was interpreted using effect sizes (regression coefficients, Odds Ratio (OR)) and Confidence Intervals (CI).

Findings

Significant and clinically relevant predictors for high symptom severity at T0 were lower education (β = -0.13, p = 0.04), pretreatment(s) (β = 0.205, p = 0.002) and migration status (β = 0.139, p = 0.023) for somatization, and potential clinically relevant predictors (|β|>0.1) for depression were living alone (β = -0.116, p = 0.083), pretreatment(s) (β = 0.118, p = 0.071) and migration status (β = 0.113, p = 0.069). At T1 patients with pretreatment(s) (OR = 0.284 [95% CI: 0.144, 0.560], p<0.001) and multiple diagnoses (OR = 0.678 [95% CI: 0.472, 0.973], p = 0.035) were significantly and clinically relevant less likely to show a remission of depressive symptoms. In addition, a potentially clinically meaningful effect of migration status on remission of depressive symptoms (OR = 0.562 [95% CI: 0.264, 1.198], p = 0.136) cannot be ruled out. For somatoform symptoms pretreatment(s) (OR = 0.403, [95% CI: 0.156, 1.041], p = 0.061) and education (OR = 1.603, [95% CI: 0.670, 3.839], p = 0.289) may be regarded as clinically relevant predictors for remission.

Conclusion

The results of our study suggest that migration status has a clinically relevant influence on severity of somatoform and depressive symptoms at admission. Clinical relevance of migration status can also be assumed regarding the remission of depression. Migration status and further factors affecting the effectiveness of the treatment should be analyzed in future research among larger samples with sufficient power to replicate these findings.