Depression symptom clusters and their predictive value for treatment outcomes: results from an individual patient data meta-analysis of duloxetine trials

Associations between somatic symptoms and remission of major depressive disorder: A longitudinal study in China

Previous studies have documented negative associations between somatic symptoms and remission of major depressive disorder (MDD). However, the correlations of specific somatic symptoms with remission remain uncertain. We aimed to explore the associations between specific somatic symptoms and remission focusing on sex differences among patients with MDD. We used data from patients with MDD in the Depression Cohort in China. At baseline, total somatic symptoms were evaluated using the 28-item Somatic Symptoms Inventory and were categorized into pain, autonomic, energy, and central nervous system (CNS) symptoms. To measure remission of MDD, depressive symptoms were evaluated using the Patient Health Questionnaire-9 after 3 months of treatment. We ultimately included 634 patients. Compared with quartile 1 of total somatic symptom scores, the full-adjusted ORs (95% CIs) for remission from quartile 2 to quartile 4 were 0.52 (0.30, 0.90), 0.44 (0.23, 0.83), and 0.36 (0.17, 0.75), respectively (P-value for trend = 0.005). The restricted cubic spline showed no non-linear associations between total somatic symptoms with remission (P-value for non-linear = 0.238). Pain, autonomic, and CNS symptoms showed similar results. Sex-stratified analysis showed that total somatic symptoms, pain symptoms, and autonomic symptoms were negatively correlated with remission in females, whereas CNS symptoms were negatively associated with remission in males. Our findings indicate that specific somatic symptoms exert differential effects on remission of MDD. Therapeutic interventions that target pain, autonomic, and CNS symptoms may increase the probability of remission. Furthermore, interventions for somatic symptoms should be tailored by sex, and females deserve more attention.

Baseline depressive symptoms as predictors of efficacy and tolerability of the treatment with duloxetine: a network analysis approach

Introduction

Depression is considered one of the most prevalent and burdensome mental disorders. Only 50-60% of patients respond to first-line treatment. Individuals with depression might benefit from personalized treatment, tailored to the individual needs of the patient. In this study, we aimed to explore the baseline characteristics of depressive symptoms associated with a good response to duloxetine treatment using a network analysis. Additionally, the relationship between baseline psychopathological symptoms and treatment tolerability was assessed.

Methods

The sample of 88 drug-free patients with active depressive episode, who started monotherapy with increasing doses of duloxetine were evaluated. The Hamilton Depression Rating Scale (HAM-D) was used to assess depression severity and the UKU side effect rating scale to monitor adverse drug reactions (ADRs). A network analysis that explored interactions of specific baseline depression symptoms, treatment efficacy and tolerability was performed.

Results

The node representing duloxetine treatment efficacy was directly connected to the nodes representing the first HAM-D item ("depressed mood") (edge weight = 0.191) and duloxetine dose (edge weight = 0.144). The node representing ADRs was directly connected to only one node representing the baseline score of the HAM-D anxiety (psychic) item (edge weight = 0.263).

Discussion

Our findings indicate that individuals with depression presenting greater levels of depressed mood and lower levels of anxiety symptoms might better respond to the treatment with duloxetine in terms of efficacy and tolerability.

Reading, Conducting, and Developing Systematic Review and Individual Patient Data Meta-Analyses in Psychiatry for Treatment Issues

Introduction: Individual participant data meta-analyses (IPD-MAs) include the raw data from relevant randomised clinical trials (RCTs) and involve secondary analyses of the data. Performed since the late 1990s, ~50 such meta-analyses have been carried out in psychiatry, mostly in the field of treatment. IPD-MAs are particularly relevant for three objectives: (1) evaluation of the average effect of an intervention by combining effects from all included trials, (2) evaluation of the heterogeneity of an intervention effect and sub-group analyses to approach personalised psychiatry, (3) mediation analysis or surrogacy evaluation to replace a clinical (final) endpoint for the evaluation of new treatments with intermediate or surrogate endpoints. The objective is to describe the interest and the steps of an IPD-MA method applied to the field of psychiatric therapeutic research. Method: The method is described in three steps. First, the identification of the relevant trials with an explicit description of the inclusion/exclusion criteria for the RCT to be incorporated in the IPD-MA and a definition of the intervention, the population, the context and the relevant points (outcomes or moderators). Second, the data management with the standardisation of collected variables and the evaluation and the assessment of the risk-of-bias for each included trial and of the global risk. Third, the statistical analyses and their interpretations, depending on the objective of the meta-analysis. All steps are illustrated with examples in psychiatry for treatment issues, excluding study protocols. Conclusion: The meta-analysis of individual patient data is challenging. Only strong collaborations between all stakeholders can make such a process efficient. An "ecosystem" that includes all stakeholders (questions of interest prioritised by the community, funders, trialists, journal editors, institutions, …) is required. International medical societies can play a central role in favouring the emergence of such communities.

Clustering patients by depression symptoms to predict venlafaxine ER antidepressant efficacy: Individual patient data analysis

OBJECTIVE

To identify clusters of patients with major depressive disorder (MDD) based on the baseline 17-item Hamilton Rating Scale for Depression (HAM-D₁₇) items and to evaluate the efficacy of venlafaxine extended release (VEN) vs placebo, and the potential effect of dose on efficacy, in each cluster.

METHODS

Cluster analysis was performed to identify clusters based on standardized HAM-D₁₇ item scores of individual patient data at baseline from 9 double-blind, placebo-controlled studies of VEN for MDD. Change from baseline in HAM-D₁₇ total score was analyzed using a mixed-effects model for repeated measures for each cluster; response and remission rates at week 8 were analyzed using logistic regression. Discontinuation rates were also evaluated in each cluster.

RESULTS

In 2599 patients, 3 patient clusters were identified, characterized as High modified Core (mCore) Symptoms/High Anxiety (cluster 1), High mCore Symptoms/Medium Anxiety (cluster 2), and Medium mCore Symptoms/Medium Anxiety (cluster 3). Significant effects of VEN vs placebo were observed on change from baseline in HAM-D₁₇ total score at week 8 for both clusters 1 and 2 (both P < 0.001), but not for cluster 3. In cluster 3, a significant treatment effect of VEN was observed at week 8 in the lower-dose subgroup but not in the higher-dose subgroup. All-cause discontinuation rates were significantly higher in placebo than VEN in each cluster.

CONCLUSIONS

Three unique clusters of patients were identified differing in baseline mCore symptoms and anxiety. Cluster membership may predict efficacy outcomes and contribute to dose effects in patients treated with VEN.

CLINICAL TRIALS REGISTRATION

NCT01441440; other studies included in this analysis were conducted before the requirement to register clinical studies took effect.

Effects of desvenlafaxine versus placebo on MDD symptom clusters: A pooled analysis

BACKGROUND

Major depressive disorder is characterized by the presence of at least five of nine specific symptoms that contribute to clinically significant functional impairment. This analysis examined the effect of desvenlafaxine (50 or 100 mg) versus placebo on symptom cluster scores and the association between early improvement in symptom clusters and symptomatic or functional remission at week 8.

METHODS

Using data from nine double-blind, placebo-controlled studies of desvenlafaxine for the treatment of major depressive disorder (N=4317), the effect of desvenlafaxine 50 or 100 mg versus placebo on scores for symptom clusters based on 17-item Hamilton Rating Scale for Depression items was assessed using analysis of covariance. Association between early improvement in symptom clusters (⩾20% improvement from baseline at week 2) and symptomatic and functional remission (17-item Hamilton Rating Scale for Depression total score ⩽7; Sheehan Disability Scale score <7) at week 8 was analyzed using logistic regression. Symptom clusters based on Montgomery-Åsberg Depression Rating Scale were also examined.

RESULTS

Desvenlafaxine 50 or 100 mg was associated with significant improvement from baseline compared to placebo for all symptom clusters (p<0.001), except a sleep cluster for desvenlafaxine 100 mg. For all symptom clusters, early improvement was significantly associated with achievement of symptomatic and functional remission at week 8 for all treatment groups (p⩽0.0254).

CONCLUSION

Early improvement in symptom clusters significantly predicts symptomatic or functional remission at week 8 in patients with depression receiving desvenlafaxine (50 or 100 mg) or placebo. Importantly, patients without early improvement were less likely to remit.

Genetic endophenotypes for insomnia of major depressive disorder and treatment-induced insomnia

Major depressive disorder (MDD) is primarily hinged on the presence of either low mood and/or anhedonia to previously pleasurable events for a minimum of 2 weeks. Other clinical features that characterize MDD include disturbances in sleep, appetite, concentration and thoughts. The combination of any/both of the primary MDD symptoms as well as any four of the other clinical features has been referred to as MDD. The challenge for replicating gene association findings with phenotypes of MDD as well as its treatment outcome is putatively due to stratification of MDD patients. Likelihood for replication of gene association findings is hypothesized with specificity in symptoms profile (homogenous clusters of symptom/individual symptoms) evaluated. The current review elucidates the genetic factors that have been associated with insomnia symptom of MDD phenotype, insomnia symptom as a constellation of neuro-vegetative cluster of MDD symptom, insomnia symptom of MDD as an individual entity and insomnia feature of treatment outcome. Homozygous CC genotype of 3111T/C, GSK3B-AT/TT genotype of rs33458 and haplotype of TPH1 218A/C were associated with insomnia symptom of MDD. Insomnia symptom of MDD was not resolved in patients with the A/A genotype of HTR2A-rs6311 when treated with SSRI. Homozygous short (SS) genotype-HTTLPR, GG genotype of HTR2A-rs6311 and CC genotype of HTR2A-rs6313 were associated with AD treatment-induced insomnia, while val/met genotype of BDNF-rs6265 and the TT genotype of GSK-3beta-rs5443 reduced it. Dearth of association studies may remain the bane for the identification of robust genetic endophenotypes in line with findings for genotypes of HTR2A-rs6311.

Depression Change Profiles in Adolescents Treated for Comorbid Depression/Substance Abuse and Profile Membership Predictors

Using data from a randomized trial in which adolescents with depressive and substance use disorders (SUD) received treatments for both disorders in either a sequenced or coordinated manner, we (a) determine the number and nature of depression response profiles through 1-year posttreatment and (b) examine whether 8 previously identified factors predict profile membership. There were 170 adolescents (M age = 16.4 years; 22% female; 28% Hispanic, 61% Non-Hispanic White) with comorbid depressive disorder/SUD randomized to one of three sequences of receiving the Adolescent Coping With Depression Course and Functional Family Therapy for SUD (depression treatment followed by SUD treatment; SUD treatment followed by depression treatment; coordinated treatment). Depression was assessed at 7 points from baseline to 1-year follow-up. A 4-class solution fit the data best, with groups labeled Mildly Depressed Responders (57.1%), Depressed Responders (18.8%), Depressed Non-Responders (12.9%), and Depressed with Recurrence (11.2%). The 4 change profiles differed on indices of all but 1 predictor (age); most differences were driven by lower scores among Mildly Depressed Responders. Profile membership was most strongly predicted by depression severity, cognitive distortions, hopelessness, and global functioning. The strongest predictor of Nonresponse was low family cohesion, whereas Recurrence was associated with hopelessness, suicide attempts, and starting treatment near the end of the school year. Most depressed adolescents experienced a positive response that was maintained. Understanding the most common profiles of depression change during and following treatment and the variables that predict change can help improve treatment outcomes and advance tailoring efforts.

Impact of demographic factors on the antidepressant effect: A patient-level data analysis from depression trials submitted to the Pharmaceuticals and Medical Devices Agency in Japan

A substantial and variable placebo response can cause unreliable findings in clinical trials designed to demonstrate the efficacy of antidepressants, and the high rate of failed trials represents a major obstacle in the development of new drugs for major depressive disorder (MDD). However, the influence of demographic and symptom factors on the antidepressant effect remains to be established. The purpose of this study was to estimate the magnitude of this influence. A patient-level meta-analysis of data from double-blind, randomized, placebo-controlled trials involving the use of antidepressants for adults with MDD was performed. Data from five confirmatory trials evaluating the efficacy of four antidepressants that were submitted to the Pharmaceuticals and Medical Devices Agency (PMDA) to support new drug applications were pooled (n = 1898). The change in the total score of 17-item Hamilton Depression Rating Scale (HDRS₁₇) was the primary outcome of interest in our analysis. The changes in the total HDRS₁₇ score in both the antidepressant medication group (ADM) and the placebo group (PBO) increased in relation to baseline symptom severity. Among older patients and those with a history of prior treatment with antidepressants, the changes in the total HDRS₁₇ score decreased in ADM and remained static in PBO. There were no notable clinical symptoms that influenced the change in the total HDRS₁₇ score. Baseline symptom severity, participant age and a history of previous treatment with antidepressants were suggested as moderators of the antidepressant effect. The drug-placebo difference in the estimated changes as a function of baseline symptom severity varied depending on the regression models used, and further studies are required to investigate appropriate models.

Effect of TCM music therapy for hospice care of patients with gastrointestinal cancer

AIM

To evaluate the effect of TCM music therapy for hospice care of patients with gastrointestinal cancer.

METHODS

One hundred and six patients with gastrointestinal cancer treated from April 2013 to January 2016 in the hospice ward of our hospital were randomly divided into either an observation group to receive TCM music therapy or a control group to receive basic therapy. Hamilton Depression Scale (HAMD) score, Karnofsky performance scale (KPS) score, and nursing satisfaction were compared between the two groups.

RESULTS

At 2 and 4 wk after treatment, the HAMD scores were significantly increased and the KPS scores were significantly decreased in both groups (P < 0.05), and the improvement was significantly better in the observation group than in the control group (P < 0.05). The rate of nursing satisfaction was significantly higher in the observation group than in the control group (90.57% vs 69.81%).

CONCLUSION

Chinese music therapy can significantly improve the hospice care of patients in terms of reducing depression and improving the functional status of patients.

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.

Treatment outcome variation between depression symptom combinations in the STAR*D study

BACKGROUND

In response to recent documentation of symptom and subtype heterogeneity in major depressive disorder, we report on exploratory analyses of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) clinical-trial data to further describe heterogeneity in depression and test the hypothesis that citalopram treatment-outcome patterns differ as a function of depression symptom combinations.

METHODS

Combinatorial algorithms, latent profile analysis, and repeated-measures multivariate analysis of variance were employed to characterize heterogeneity and depression outcome-measure profile variability in the most prevalent symptom combinations with full data (26% of baseline and 13% of endpoint total sample).

RESULTS

Descriptive results suggest that substantial heterogeneity and moderate coherence characterize major depressive disorder; as in previous analyses, pairs of individuals sharing no symptoms in common were observed. Exploratory latent profile analysis indicated that different patterns of treatment outcome data exist among STAR*D participants. A small but significant interaction effect of symptom combination×outcome measure profile was observed for clinician-rated but not self-reported symptom combinations.

LIMITATIONS

Factors moderating the generalizability of these findings include binary symptom measures, a short treatment period, and a smaller number of individuals per combination.

CONCLUSIONS

These results provide evidence that citalopram treatment outcomes vary as a function of diagnostic combinations, thereby providing preliminary evidence that the substantial heterogeneity documented in depression symptom presentations may carry implications for prognosis and treatment outcome. At the level of descriptive phenomenology, these results appear to corroborate the claim that depression is not a homogenous syndrome.