1
|
Serbanescu I, Schramm E, Walter H, Schnell K, Zobel I, Drost S, Fangmeier T, Normann C, Schoepf D. Identifying subgroups with differential response to CBASP versus Escitalopram during the first eight weeks of treatment in outpatients with persistent depressive disorder. Eur Arch Psychiatry Clin Neurosci 2024; 274:723-737. [PMID: 37606728 PMCID: PMC10995028 DOI: 10.1007/s00406-023-01672-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
There exists little empirical evidence helping clinicians to select the most effective treatment for individual patients with persistent depressive disorder (PDD). This study identifies and characterizes subgroups of patients with PDD who are likely to benefit more from an acute treatment with psychotherapy than from pharmacotherapy and vice versa. Non-medicated outpatients with PDD were randomized to eight weeks of acute treatment with the Cognitive Behavioral Analysis System of Psychotherapy (CBASP; n = 29) or escitalopram plus clinical management (ESC/CM; n = 31). We combined several baseline variables to one composite moderator and identified two subgroups of patients: for 56.0%, ESC/CM was associated with a greater reduction in depression severity than CBASP, for the remaining 44.0%, it was the other way around. Patients likely to benefit more from ESC/CM were more often female, had higher rates of moderate-to-severe childhood trauma, more adverse life events and more previous suicide attempts. Patients likely to benefit more from CBASP were older, had more often an early illness onset and more previous treatments with antidepressants. Symptomatic response, remission, and reductions in symptom severity occurred more often in those patients treated with their likely more effective treatment condition. The findings suggest that the baseline phenotype of patients with PDD moderates their benefit from acute treatment with CBASP relative to ESC/CM. Once confirmed in an independent sample, these results could serve to guide the choice between primarily psychotherapeutic or pharmacological treatments for outpatients with PDD.
Collapse
Affiliation(s)
- Ilinca Serbanescu
- Institute of Psychology, Heidelberg University, Hauptstrasse 47-51, 69117, Heidelberg, Germany.
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Hauptstrasse 5, 79104, Freiburg, Germany
| | - Henrik Walter
- Department of Psychiatry and Psychotherapy, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Knut Schnell
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Rosdorfer Weg 70, 37081, Göttingen, Germany
| | - Ingo Zobel
- Psychology School at the Fresenius University of Applied Sciences Berlin, Jägerstrasse 32, 10117, Berlin, Germany
| | - Sarah Drost
- Department of Psychiatry and Psychotherapy, CBASP Center of Competence, University Medical Center Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Thomas Fangmeier
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Hauptstrasse 5, 79104, Freiburg, Germany
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Hauptstrasse 5, 79104, Freiburg, Germany
| | - Dieter Schoepf
- Department of Psychiatry and Psychotherapy, CBASP Center of Competence, University Medical Center Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| |
Collapse
|
2
|
Blaszczyk AT, Mathys M, Le J. A Review of Therapeutics for Treatment-Resistant Depression in the Older Adult. Drugs Aging 2023; 40:785-813. [PMID: 37596380 DOI: 10.1007/s40266-023-01051-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/20/2023]
Abstract
One-third of older adults with depression meet criteria for treatment resistance, typically defined as a lack of response to two or more adequate trials of an antidepressant. Treatment resistance contributes to an unfavorable prognosis, compromised medical outcomes, heightened disability, accelerated cognitive decline, and an elevated risk of developing dementia. Despite this significant morbidity, evidence is sparse for how to proceed with treatment in this population. Non-pharmacologic therapy (e.g., diet, psychotherapy) can be utilized as adjunctive therapy, despite little published evidence of benefit, given that the risks are low. Pharmacotherapy trials in the treatment-resistant late-life depression population lack strong methods and external validity; however, the use of venlafaxine as monotherapy and add-on therapy, as well as lithium, bupropion, or aripiprazole as add-on therapy to standard antidepressant therapy, have enough evidence that a trial with appropriate monitoring is a prudent strategy. Electroconvulsive therapy remains a well-studied safe therapy, especially when used as maintenance treatment once an initial cycle is completed but is traditionally underutilized in the treatment-resistant late-life depression population. Ensuring non-pharmacologic and pharmacologic strategies are optimized and given a sufficient trial in those with treatment-resistant late-life depression is the best we can do for this vulnerable population.
Collapse
Affiliation(s)
- Amie Taggart Blaszczyk
- Department of Pharmacy Practice, Texas Tech University HSC School of Pharmacy-Dallas/Fort Worth, 5920 Forest Park Rd, Dallas, TX, USA.
| | - Monica Mathys
- Department of Pharmacy Practice, Texas Tech University HSC School of Pharmacy-Dallas/Fort Worth, 5920 Forest Park Rd, Dallas, TX, USA
| | - Jennifer Le
- Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
| |
Collapse
|
3
|
Therapy Strategies for Late-life Depression: A Review. J Psychiatr Pract 2023; 29:15-30. [PMID: 36649548 DOI: 10.1097/pra.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Depression in the elderly requires different treatment options because therapies that are commonly used for depression in younger patients show different effects later in life. Treatment options for late-life depression (LLD) are summarized in this article. METHODS A literature search in Medline/PubMed performed in June 2020 identified 83 relevant studies. RESULTS Pharmacotherapy with selective serotonin reuptake inhibitors can be an effective first-line treatment in LLD, but >50% of elderly patients do not adequately respond. Switching to other selective serotonin reuptake inhibitors or augmenting with mood stabilizers or antipsychotics is often effective in achieving a therapeutic benefit. Severely depressed patients with a high risk of suicidal behavior can be treated with electroconvulsive therapy. Psychotherapy provides a measurable benefit alone and when combined with medication. LIMITATIONS LLD remains an underrepresented domain in research. Paucity of data concerning the effect of specific therapies for LLD, heterogeneity in the quality of study designs, overinterpretation of results from meta-analyses, and discrepancies between study results and guideline recommendations were often noted. CONCLUSIONS Treating LLD is complex, but there are several treatment options with good efficacy and tolerability. Some novel pharmaceuticals also show promise as potential antidepressants, but evidence for their efficacy and safety is still limited and based on only a few trials conducted to date.
Collapse
|
4
|
International pooled patient-level meta-analysis of ketamine infusion for depression: In search of clinical moderators. Mol Psychiatry 2022; 27:5096-5112. [PMID: 36071111 PMCID: PMC9763119 DOI: 10.1038/s41380-022-01757-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023]
Abstract
Depression is disabling and highly prevalent. Intravenous (IV) ketamine displays rapid-onset antidepressant properties, but little is known regarding which patients are most likely to benefit, limiting personalized prescriptions. We identified randomized controlled trials of IV ketamine that recruited individuals with a relevant psychiatric diagnosis (e.g., unipolar or bipolar depression; post-traumatic stress disorder), included one or more control arms, did not provide any other study-administered treatment in conjunction with ketamine (although clinically prescribed concurrent treatments were allowable), and assessed outcome using either the Montgomery-Åsberg Depression Rating Scale or the Hamilton Rating Scale for Depression (HRSD-17). Individual patient-level data for at least one outcome was obtained from 17 of 25 eligible trials [pooled n = 809]. Rates of participant-level data availability across 33 moderators that were solicited from these 17 studies ranged from 10.8% to 100% (median = 55.6%). After data harmonization, moderators available in at least 40% of the dataset were tested sequentially, as well as with a data-driven, combined moderator approach. Robust main effects of ketamine on acute [~24-hours; β*(95% CI) = 0.58 (0.44, 0.72); p < 0.0001] and post-acute [~7 days; β*(95% CI) = 0.38 (0.23, 0.54); p < 0.0001] depression severity were observed. Two study-level moderators emerged as significant: ketamine effects (relative to placebo) were larger in studies that required a higher degree of previous treatment resistance to federal regulatory agency-approved antidepressant medications (≥2 failed trials) for study entry; and in studies that used a crossover design. A comprehensive data-driven search for combined moderators identified statistically significant, but modest and clinically uninformative, effects (effect size r ≤ 0.29, a small-medium effect). Ketamine robustly reduces depressive symptoms in a heterogeneous range of patients, with benefit relative to placebo even greater in patients more resistant to prior medications. In this largest effort to date to apply precision medicine approaches to ketamine treatment, no clinical or demographic patient-level features were detected that could be used to guide ketamine treatment decisions.Review Registration: PROSPERO Identifier: CRD42021235630.
Collapse
|
5
|
Brewster KK, Zilcha-Mano S, Wallace ML, Kim AH, Brown PJ, Roose SP, Golub JS, Galatioto J, Kuhlmey M, Rutherford BR. A precision medicine tool to understand who responds best to hearing aids in late-life depression. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5721. [PMID: 35499363 PMCID: PMC9942910 DOI: 10.1002/gps.5721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/20/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Accumulating evidence suggests that hearing loss (HL) treatment may benefit depressive symptoms among older adults with Major Depressive Disorder (MDD), but the specific individual characteristics of those who stand to improve most are unknown. METHODS N = 37 patients ≥60 years with HL and MDD received either active or sham hearing aids in this 12-week double-blind randomized controlled trial. A combined moderator approach was utilized in the analysis in order to examine multiple different pretreatment individual characteristics to determine the specific qualities that predicted the best depressive symptom response to hearing aids. Pretreatment characteristics included: Hearing Handicap Inventory for the Elderly (HHIE-S), pure tone average (PTA), speech reception threshold (SRT), Short Physical Performance Battery (SPPB), cognition (Repeatable Battery for the Assessment of Neuropsychological Status). RESULTS The analysis revealed a combined moderator, predicting greater improvement with active versus sham hearing aids, that had a larger effect size than any individual moderator (combined effect size [ES] = 0.49 [95% CI: 0.36, 0.76]). Individuals with worse hearing-related disability (HHIE-S: individual ES = -0.16), speech recognition (SRT: individual ES = -0.14), physical performance (SPPB: individual ES = 0.41), and language functioning (individual ES = 0.19) but with relatively less severe audiometric thresholds (PTA: individual ES = 0.17) experienced greater depressive symptom improvement with active hearing aids. CONCLUSIONS Older adults with relatively worse HL-related, physical, and cognitive functioning may stand to benefit most from hearing aids. Given the large number of older adults experiencing HL and MDD, a non-invasive and scalable means of targeting those most likely to respond to interventions would be valuable.
Collapse
Affiliation(s)
- Katharine K. Brewster
- Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Drive, Box 92, New York, NY 10032
| | | | | | - Ana H. Kim
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University, Department of Otolaryngology—Head and Neck Surgery
| | - Patrick J. Brown
- Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute
| | - Steven P. Roose
- Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute
| | - Justin S. Golub
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University, Department of Otolaryngology—Head and Neck Surgery
| | - Jessica Galatioto
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University, Department of Otolaryngology—Head and Neck Surgery
| | - Megan Kuhlmey
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Department of Otolaryngology—Head and Neck Surgery
| | - Bret R. Rutherford
- Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute
| |
Collapse
|
6
|
Zilcha-Mano S, Wallace ML, Brown PJ, Sneed J, Roose SP, Rutherford BR. Who benefits most from expectancy effects? A combined neuroimaging and antidepressant trial in depressed older adults. Transl Psychiatry 2021; 11:475. [PMID: 34526482 PMCID: PMC8443672 DOI: 10.1038/s41398-021-01606-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/27/2021] [Accepted: 08/12/2021] [Indexed: 12/22/2022] Open
Abstract
Depressed patients' expectations of improvement drive placebo effects in antidepressant clinical trials, yet there is considerable heterogeneity in the magnitude of expectancy effects. The present study seeks to identify those individuals who benefit most from expectancy effects using baseline neuroimaging and cognitive measures. Older adult outpatients diagnosed with major depressive disorder (MDD) participated in a prospective, 8-week clinical trial in which expectancy was experimentally manipulated and its effects on depression outcome measured. Based on the literature, we selected a priori 12 cognitive and brain-based variables linked to depression and expectancy, together with demographic variables, and incorporated them into a combined moderator. The combined moderator was developed as a weighted combination of the individual moderators, and was used to identify individuals who benefited most from expectancy effects. The combined moderator was found to predict differential change in depression severity scores between the high- vs. low-expectancy groups with a medium-size effect (Spearman effect size: 0.28). While at the sample level no expectancy effect was found, the combined moderator divided older adults with MDD into those who did and those who did not improve as the result of expectancy manipulation, with those benefiting from the manipulation showing greater processing speed, executive function, and frontostriatal white matter tract integrity. The findings suggest that it is possible to identify a subgroup of older adult individuals with MDD for whom expectancy manipulation results in greater antidepressant treatment response, supporting a precision medicine approach. This subgroup is characterized by distinct cognitive dysfunction and neuroimaging impairments profiles.
Collapse
Affiliation(s)
- Sigal Zilcha-Mano
- Department of Psychology, University of Haifa, Mount Carmel, 31905, Haifa, Israel.
| | - Meredith L. Wallace
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh Department of Psychiatry, Statistics, and Biostatistics, Pittsburgh, PA USA
| | - Patrick J. Brown
- grid.413734.60000 0000 8499 1112Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY USA
| | - Joel Sneed
- grid.262273.00000 0001 2188 3760Queens College of the City University of New York, New York, NY USA
| | - Steven P. Roose
- grid.413734.60000 0000 8499 1112Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY USA
| | - Bret R. Rutherford
- grid.413734.60000 0000 8499 1112Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY USA
| |
Collapse
|
7
|
van Bronswijk SC, DeRubeis RJ, Lemmens LHJM, Peeters FPML, Keefe JR, Cohen ZD, Huibers MJH. Precision medicine for long-term depression outcomes using the Personalized Advantage Index approach: cognitive therapy or interpersonal psychotherapy? Psychol Med 2021; 51:279-289. [PMID: 31753043 PMCID: PMC7893512 DOI: 10.1017/s0033291719003192] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 10/08/2019] [Accepted: 10/21/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Psychotherapies for depression are equally effective on average, but individual responses vary widely. Outcomes can be improved by optimizing treatment selection using multivariate prediction models. A promising approach is the Personalized Advantage Index (PAI) that predicts the optimal treatment for a given individual and the magnitude of the advantage. The current study aimed to extend the PAI to long-term depression outcomes after acute-phase psychotherapy. METHODS Data come from a randomized trial comparing cognitive therapy (CT, n = 76) and interpersonal psychotherapy (IPT, n = 75) for major depressive disorder (MDD). Primary outcome was depression severity, as assessed by the BDI-II, during 17-month follow-up. First, predictors and moderators were selected from 38 pre-treatment variables using a two-step machine learning approach. Second, predictors and moderators were combined into a final model, from which PAI predictions were computed with cross-validation. Long-term PAI predictions were then compared to actual follow-up outcomes and post-treatment PAI predictions. RESULTS One predictor (parental alcohol abuse) and two moderators (recent life events; childhood maltreatment) were identified. Individuals assigned to their PAI-indicated treatment had lower follow-up depression severity compared to those assigned to their PAI-non-indicated treatment. This difference was significant in two subsets of the overall sample: those whose PAI score was in the upper 60%, and those whose PAI indicated CT, irrespective of magnitude. Long-term predictions did not overlap substantially with predictions for acute benefit. CONCLUSIONS If replicated, long-term PAI predictions could enhance precision medicine by selecting the optimal treatment for a given depressed individual over the long term.
Collapse
Affiliation(s)
- Suzanne C. van Bronswijk
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | | | - Lotte H. J. M. Lemmens
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - Frenk P. M. L. Peeters
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - John R. Keefe
- Department of Psychiatry, Weill Cornell Medical College, New York, USA
| | - Zachary D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Marcus J. H. Huibers
- Department of Psychology, University of Pennsylvania, Philadelphia, USA
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
8
|
de la Rie SM, Smid GE, van der Aa N, van Est LAC, Bisseling E, Boelen PA. Feasibility of narrative exposure therapy in an outpatient day treatment programme for refugees: improvement in symptoms and global functioning. Eur J Psychotraumatol 2020; 11:1759983. [PMID: 33029303 PMCID: PMC7473203 DOI: 10.1080/20008198.2020.1759983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Refugees are at high risk for developing post-traumatic stress disorder (PTSD). Narrative exposure therapy (NET) is an evidence-based treatment of PTSD, designed for patients exposed to (multiple) traumatic events and recommended for patients with culturally diverse backgrounds. In clinical practice, adherence to the NET-protocol has been challenged because of psychosocial complexities and comorbid disorders. . OBJECTIVE The current study investigated the feasibility of NET embedded in an outpatient day treatment programme for refugees and examined reduction in PTSD symptoms and improvement of global functioning as well as correlates of change. . METHOD Participants were patients who consecutively entered an outpatient daytreatment programme from 2013-2017. The majority had a history of prior unsuccessful treatment. PTSD was assessed with the Clinically Administered PTSD Scale (CAPS) before and after finishing NET. Global Assessment of Functioning (GAF) was used to examine changes in functioning. Changes in PTSD scores and functioning were analyzed using paired t-tests and reliable change indices. Patients showing significant improvement were compared to those who did not, on patient and treatment characteristics, including sex, age, region of origin, childhood trauma and treatment duration and dosage of NET. . RESULTS Of 97 patients, 76 (78.4%) completed NET. Completers had a longer residency and were more likely to have a partner. Significant reductions in PTSD symptoms and improvements in global functioning were observed. Twenty-eight percent showed reliable improvement with large effect sizes. Four patients did no longer meet the criteria for PTSD. No strong moderators for changes were found. Patients who did not improve more often had a history of childhood trauma. CONCLUSIONS NET embedded in an outpatient day treatment programme appears to be feasible. In those who improved, a substantial decline in symptoms and improvement of functioning were observed. The findings suggest that a socially supportive living environment enhances acceptability of trauma-focused treatment in refugees.
Collapse
Affiliation(s)
- Simone M de la Rie
- ARQ National Psychotrauma Centre, ARQ Centrum'45, Diemen, The Netherlands
| | - Geert E Smid
- ARQ National Psychotrauma Centre, ARQ Centrum'45, Diemen, The Netherlands.,University of Humanistic Studies, Utrecht, The Netherlands
| | - Niels van der Aa
- ARQ National Psychotrauma Centre, ARQ Centrum'45, Diemen, The Netherlands
| | - Leanne A C van Est
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands.,Reinier van Arkel, Psychotraumacentrum Zuid Nederland, 's Hertogenbosch, The Netherlands
| | - Eef Bisseling
- ARQ National Psychotrauma Centre, ARQ Centrum'45, Diemen, The Netherlands
| | - Paul A Boelen
- ARQ National Psychotrauma Centre, ARQ Centrum'45, Diemen, The Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
9
|
Personalized Psychotherapy for Outpatients with Major Depression and Anxiety Disorders: Transdiagnostic Versus Diagnosis-Specific Group Cognitive Behavioural Therapy. COGNITIVE THERAPY AND RESEARCH 2020. [DOI: 10.1007/s10608-020-10116-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Only about half of all patients with anxiety disorders or major depression respond to cognitive behaviour therapy (CBT), even though this is an evidence-based treatment. Personalized treatment offers an approach to increase the number of patients who respond to therapy. The aim of this study was to examine predictors and moderators of (differential) treatment outcomes in transdiagnostic versus diagnosis-specific group CBT.
Methods
A sample of 291 patients from three different mental health clinics in Denmark was randomized to either transdiagnostic or diagnosis-specific group CBT. The study outcome was the regression slope of the individual patient's repeated scores on the WHO-5 Well-being Index. Pre-treatment variables were identified as moderators or predictors through a two-step variable selection approach.
Results
While the two-step approach failed to identify any moderators, four predictors were found: level of positive affect, duration of disorder, the detachment personality trait, and the coping strategy of cognitive reappraisal. A prognostic index was constructed, but did not seem to be robust across treatment sites.
Conclusions
Our findings give insufficient evidence to support a recommendation of either transdiagnostic or diagnosis-specific CBT for a given patient or to predict the response to the applied group therapies.
Collapse
|
10
|
|
11
|
Davies P, Ijaz S, Williams CJ, Kessler D, Lewis G, Wiles N. Pharmacological interventions for treatment-resistant depression in adults. Cochrane Database Syst Rev 2019; 12:CD010557. [PMID: 31846068 PMCID: PMC6916711 DOI: 10.1002/14651858.cd010557.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although antidepressants are often a first-line treatment for adults with moderate to severe depression, many people do not respond adequately to medication, and are said to have treatment-resistant depression (TRD). Little evidence exists to inform the most appropriate 'next step' treatment for these people. OBJECTIVES To assess the effectiveness of standard pharmacological treatments for adults with TRD. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (March 2016), CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science (31 December 2018), the World Health Organization trials portal and ClinicalTrials.gov for unpublished and ongoing studies, and screened bibliographies of included studies and relevant systematic reviews without date or language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with participants aged 18 to 74 years with unipolar depression (based on criteria from DSM-IV-TR or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria or Research Diagnostic Criteria) who had not responded to a minimum of four weeks of antidepressant treatment at a recommended dose. Interventions were: (1) increasing the dose of antidepressant monotherapy; (2) switching to a different antidepressant monotherapy; (3) augmenting treatment with another antidepressant; (4) augmenting treatment with a non-antidepressant. All were compared with continuing antidepressant monotherapy. We excluded studies of non-standard pharmacological treatments (e.g. sex hormones, vitamins, herbal medicines and food supplements). DATA COLLECTION AND ANALYSIS Two reviewers used standard Cochrane methods to extract data, assess risk of bias, and resolve disagreements. We analysed continuous outcomes with mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (CI). For dichotomous outcomes, we calculated a relative risk (RR) and 95% CI. Where sufficient data existed, we conducted meta-analyses using random-effects models. MAIN RESULTS We included 10 RCTs (2731 participants). Nine were conducted in outpatient settings and one in both in- and outpatients. Mean age of participants ranged from 42 - 50.2 years, and most were female. One study investigated switching to, or augmenting current antidepressant treatment with, another antidepressant (mianserin). Another augmented current antidepressant treatment with the antidepressant mirtazapine. Eight studies augmented current antidepressant treatment with a non-antidepressant (either an anxiolytic (buspirone) or an antipsychotic (cariprazine; olanzapine; quetiapine (3 studies); or ziprasidone (2 studies)). We judged most studies to be at a low or unclear risk of bias. Only one of the included studies was not industry-sponsored. There was no evidence of a difference in depression severity when current treatment was switched to mianserin (MD on Hamilton Rating Scale for Depression (HAM-D) = -1.8, 95% CI -5.22 to 1.62, low-quality evidence)) compared with continuing on antidepressant monotherapy. Nor was there evidence of a difference in numbers dropping out of treatment (RR 2.08, 95% CI 0.94 to 4.59, low-quality evidence; dropouts 38% in the mianserin switch group; 18% in the control). Augmenting current antidepressant treatment with mianserin was associated with an improvement in depression symptoms severity scores from baseline (MD on HAM-D -4.8, 95% CI -8.18 to -1.42; moderate-quality evidence). There was no evidence of a difference in numbers dropping out (RR 1.02, 95% CI 0.38 to 2.72; low-quality evidence; 19% dropouts in the mianserin-augmented group; 38% in the control). When current antidepressant treatment was augmented with mirtazapine, there was little difference in depressive symptoms (MD on Beck Depression Inventory (BDI-II) -1.7, 95% CI -4.03 to 0.63; high-quality evidence) and no evidence of a difference in dropout numbers (RR 0.50, 95% CI 0.15 to 1.62; dropouts 2% in mirtazapine-augmented group; 3% in the control). Augmentation with buspirone provided no evidence of a benefit in terms of a reduction in depressive symptoms (MD on Montgomery and Asberg Depression Rating Scale (MADRS) -0.30, 95% CI -9.48 to 8.88; low-quality evidence) or numbers of drop-outs (RR 0.60, 95% CI 0.23 to 1.53; low-quality evidence; dropouts 11% in buspirone-augmented group; 19% in the control). Severity of depressive symptoms reduced when current treatment was augmented with cariprazine (MD on MADRS -1.50, 95% CI -2.74 to -0.25; high-quality evidence), olanzapine (MD on HAM-D -7.9, 95% CI -16.76 to 0.96; low-quality evidence; MD on MADRS -12.4, 95% CI -22.44 to -2.36; low-quality evidence), quetiapine (SMD -0.32, 95% CI -0.46 to -0.18; I2 = 6%, high-quality evidence), or ziprasidone (MD on HAM-D -2.73, 95% CI -4.53 to -0.93; I2 = 0, moderate-quality evidence) compared with continuing on antidepressant monotherapy. However, a greater number of participants dropped out when antidepressant monotherapy was augmented with an antipsychotic (cariprazine RR 1.68, 95% CI 1.16 to 2.41; quetiapine RR 1.57, 95% CI: 1.14 to 2.17; ziprasidone RR 1.60, 95% CI 1.01 to 2.55) compared with antidepressant monotherapy, although estimates for olanzapine augmentation were imprecise (RR 0.33, 95% CI 0.04 to 2.69). Dropout rates ranged from 10% to 39% in the groups augmented with an antipsychotic, and from 12% to 23% in the comparison groups. The most common reasons for dropping out were side effects or adverse events. We also summarised data about response and remission rates (based on changes in depressive symptoms) for included studies, along with data on social adjustment and social functioning, quality of life, economic outcomes and adverse events. AUTHORS' CONCLUSIONS A small body of evidence shows that augmenting current antidepressant therapy with mianserin or with an antipsychotic (cariprazine, olanzapine, quetiapine or ziprasidone) improves depressive symptoms over the short-term (8 to 12 weeks). However, this evidence is mostly of low or moderate quality due to imprecision of the estimates of effects. Improvements with antipsychotics need to be balanced against the increased likelihood of dropping out of treatment or experiencing an adverse event. Augmentation of current antidepressant therapy with a second antidepressant, mirtazapine, does not produce a clinically important benefit in reduction of depressive symptoms (high-quality evidence). The evidence regarding the effects of augmenting current antidepressant therapy with buspirone or switching current antidepressant treatment to mianserin is currently insufficient. Further trials are needed to increase the certainty of these findings and to examine long-term effects of treatment, as well as the effectiveness of other pharmacological treatment strategies.
Collapse
Affiliation(s)
- Philippa Davies
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
- University Hospitals Bristol NHS Foundation TrustNIHR ARC WestBristolUK
| | - Sharea Ijaz
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
- University Hospitals Bristol NHS Foundation TrustNIHR ARC WestBristolUK
| | - Catherine J Williams
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - David Kessler
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | - Glyn Lewis
- UCLUCL Division of Psychiatry67‐73 Riding House StLondonUKW1W 7EJ
| | - Nicola Wiles
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | | |
Collapse
|
12
|
Serbanescu I, Walter H, Schnell K, Kessler H, Weber B, Drost S, Groß M, Neudeck P, Klein JP, Assmann N, Zobel I, Backenstrass M, Hautzinger M, Meister R, Härter M, Schramm E, Schoepf D. Combining baseline characteristics to disentangle response differences to disorder-specific versus supportive psychotherapy in patients with persistent depressive disorder. Behav Res Ther 2019; 124:103512. [PMID: 31734568 DOI: 10.1016/j.brat.2019.103512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/14/2019] [Accepted: 11/03/2019] [Indexed: 12/24/2022]
Abstract
Does the pre-treatment profile of individuals with persistent depressive disorder (PDD) moderate their benefit from disorder-specific Cognitive Behavioral System of Psychotherapy (CBASP) versus supportive psychotherapy (SP)? We investigated this question by analyzing data from a multi-center randomized clinical trial comparing the effectiveness of 48 weeks of CBASP to SP in n = 237 patients with early-onset PDD who were not taking antidepressant medication. We statistically developed an optimal composite moderator as a weighted combination of 13 preselected baseline variables and used it for identifying and characterizing subgroups for which CABSP may be preferable to SP or vice versa. We identified two distinct subgroups: 58.65% of the patients had a better treatment outcome with CBASP, while the remaining 41.35% had a better outcome with SP. At baseline, patients responding more favorably to CBASP were more severely depressed and more likely affected by moderate-to-severe childhood trauma including early emotional, physical, or sexual abuse, as well as emotional or physical neglect. In contrast, patients responding more favorably to SP had a higher pre-treatment global and social functioning level, a higher life quality and more often a recurrent illness pattern without complete remission between the episodes. These findings emphasize the relevance of considering pre-treatment characteristics when selecting between disorder-specific CBASP and SP for treating PDD. The practical implementation of this approach would advance personalized medicine for PDD by supporting mental health practitioners in their selection of the most effective psychotherapy for an individual patient.
Collapse
Affiliation(s)
- Ilinca Serbanescu
- Center for Economics and Neuroscience, University of Bonn, Nachtigallenweg 86, D-53127, Bonn, Germany; Institute of Experimental Epileptology and Cognition Research, University of Bonn, Sigmund-Freud-Strasse 25, D-53127, Bonn, Germany.
| | - Henrik Walter
- Department of Psychiatry and Psychotherapy, Charité-University Medicine Berlin, Charitéplatz 1, D-10117, Berlin, Germany
| | - Knut Schnell
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, vonsiebold Straße 5, D-37075, Göttingen, Germany
| | - Henrik Kessler
- Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Alexandrinenstrasse 1-3, D-44791, Bochum, Germany
| | - Bernd Weber
- Center for Economics and Neuroscience, University of Bonn, Nachtigallenweg 86, D-53127, Bonn, Germany; Institute of Experimental Epileptology and Cognition Research, University of Bonn, Sigmund-Freud-Strasse 25, D-53127, Bonn, Germany
| | - Sarah Drost
- Department of Psychiatry and Psychotherapy, CBASP Center of Competence, University of Bonn, Sigmund-Freud-Strasse 25, D-53127, Bonn, Germany
| | - Magdalena Groß
- Department of Psychiatry and Psychotherapy, CBASP Center of Competence, University of Bonn, Sigmund-Freud-Strasse 25, D-53127, Bonn, Germany
| | - Peter Neudeck
- Department of Psychiatry and Psychotherapy, CBASP Center of Competence, University of Bonn, Sigmund-Freud-Strasse 25, D-53127, Bonn, Germany
| | - Jan Philipp Klein
- Department of Psychiatry and Psychotherapy, Lübeck University, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Nele Assmann
- Department of Psychiatry and Psychotherapy, Lübeck University, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Ingo Zobel
- Psychology School at the Fresenius University of Applied Sciences Berlin, Jägerstrasse 32, D-10117, Berlin, Germany
| | - Matthias Backenstrass
- Department of Clinical Psychology and Psychotherapy, University of Heidelberg, Hauptstrasse 47-51, D-69117, Heidelberg, Germany; Institute of Clinical Psychology, Hospital Stuttgart, Prießnitzweg 24, D-70374, Stuttgart, Germany
| | - Martin Hautzinger
- Department of Psychology, Clinical Psychology and Psychotherapy, Eberhard Karls University Tübingen, Schleichstrasse 4, D-72076, Tübingen, Germany
| | - Ramona Meister
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstrasse 5, D-79104, Freiburg, Germany
| | - Dieter Schoepf
- Department of Psychiatry and Psychotherapy, CBASP Center of Competence, University of Bonn, Sigmund-Freud-Strasse 25, D-53127, Bonn, Germany; Department of Psychiatry and Psychotherapy, Vitos Weil-Lahn, Mönchberg 8, D-65589, Hadamar, Germany
| |
Collapse
|
13
|
Getting to precision psychopharmacology: Combining clinical and genetic information to predict fat gain from aripiprazole. J Psychiatr Res 2019; 114:67-74. [PMID: 31039482 PMCID: PMC6546502 DOI: 10.1016/j.jpsychires.2019.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/12/2019] [Accepted: 04/18/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION All atypical antipsychotics are associated with some degree of weight gain. We applied a novel statistical approach to identify moderators of aripiprazole-induced fat gain using clinical and genetic data from a randomized clinical trial (RCT) of treatment resistant depression in older adults. MATERIALS AND METHODS Adults aged ≥60 years with non-response to a prospective trial of venlafaxine were randomized to 12 weeks of aripiprazole augmentation (n = 91) or placebo (n = 90). Dual energy x-ray absorptiometry (DEXA) measured adiposity at baseline and 12 weeks. Independent moderators of total body fat gain were used to generate two combined multiple moderators, one including clinical data alone and one including both clinical and genetic data to characterize individuals who gained fat during aripiprazole augmentation. RESULTS The value of the combined genetic + clinical multiple moderator (Mcg) was 0.57 [95% CI 0.46, 0.68] (effect size: 0.57), compared to the combined clinical moderator (Mc) value of 0.49 [0.34, 0.63] (effect size: 0.49). Individuals who gained adiposity in this study were more likely to be female and younger in age, have lower weight, fasting glucose and lipids at baseline and positive for the HTR2C polymorphism. DISCUSSION These results demonstrate a combined multiple moderator approach, including both clinical and genetic moderators, can be applied to existing clinical trial data to understand adverse treatment effects. This method allowed for more specific characterization of individuals at risk for the outcome of interest. Further work is needed to identify additional genetic moderators and to validate the approach.
Collapse
|
14
|
Cohen ZD, Kim TT, Van HL, Dekker JJM, Driessen E. A demonstration of a multi-method variable selection approach for treatment selection: Recommending cognitive–behavioral versus psychodynamic therapy for mild to moderate adult depression. Psychother Res 2019; 30:137-150. [DOI: 10.1080/10503307.2018.1563312] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Zachary D. Cohen
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas T. Kim
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Jack J. M. Dekker
- Arkin Mental Health Care, Amsterdam, The Netherlands
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ellen Driessen
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Abstract
OBJECTIVE Although cognitive behavior therapy (CBT) is efficacious for major depression in patients with heart failure (HF), approximately half of patients do not remit after CBT. To identify treatment moderators that may help guide treatment allocation strategies and serve as new treatment targets, we performed a secondary analysis of a randomized clinical trial. Based on evidence of their prognostic relevance, we evaluated whether clinical and activity characteristics moderate the effects of CBT. METHODS Participants were randomized to enhanced usual care (UC) alone or CBT plus enhanced UC. The single-blinded outcomes were 6-month changes in Beck Depression Inventory total scores and remission (defined as a Beck Depression Inventory ≤ 9). Actigraphy was used to assess daily physical activity patterns. We performed analyses to identify the specific activity and clinical moderators of the effects of CBT in 94 adults (mean age = 58, 49% female) with HF and major depressive disorder. RESULTS Patients benefited more from CBT (versus UC) if they had the following: more medically severe HF (i.e., a higher New York Heart Association class or a lower left ventricular ejection fraction), more stable activity patterns, wider active periods, and later evening settling times. These individual moderator effects were small (|r| = 0.10-0.21), but combining the moderators yielded a medium moderator effect size (r = 0.38; 95% CI = 0.20-0.52). CONCLUSIONS These findings suggest that increasing the cross-daily stability of activity patterns, and prolonging the daily active period, might help increase the efficacy of CBT. Given moderating effects of HF severity measures, research is also needed to clarify and address factors in patients with less severe HF that diminish the efficacy of CBT. CLINICAL TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01028625.
Collapse
|
16
|
Using optimal combined moderators to define heterogeneity in neural responses to randomized conditions: Application to the effect of sleep loss on fear learning. Neuroimage 2018; 181:718-727. [PMID: 30041060 DOI: 10.1016/j.neuroimage.2018.07.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 07/18/2018] [Accepted: 07/21/2018] [Indexed: 12/24/2022] Open
Abstract
Comparing the neural outcomes of two randomized experimental groups is a primary aim of many functional neuroimaging studies. However, between-group effects can be obscured by heterogeneity in neural responses. Optimal Combined Moderator (OCM) approaches have previously been used to clarify heterogeneity in clinical outcomes following treatment randomization. We show that OCMs can also be used to clarify heterogeneity in the effect of a randomized experimental condition on neural responses. In 78 healthy adults aged 18-30 from the Effects of Dose-Dependent Sleep Disruption on Fear and Reward (SFeRe) study, we used demographic, clinical, genetic, and polysomnographic characteristics to develop OCMs for the effect of a randomized sleep restriction (SR) versus normal sleep (NS) condition on blood-oxygen-level dependent responses in the right amygdala (RAmyg) and subgenual anterior cingulate cortex (sgACC) during fear conditioning (FC) and extinction (FE) paradigms. The OCM for the RAmyg during FE was strongest [r (95% CI) = 0.52 (0.42, 0.68)], withstood cross-validation, and divided the sample into two subgroups with opposing experimental effects. Among N = 48 participants ("SR < NS"), those with SR exhibited less RAmyg activation during FE than those with NS [d (95%CI) = -1.10 (-1.86, -0.77)]. Among the remaining N = 30 participants ("SR > NS"), those with SR exhibited greater RAmyg activation during FE following SR than those with NS [d (95%CI) = 0.87 (0.37,1.78)]. SR > NS participants were more likely to be female, white, l/l genotype carriers, and have a psychiatric history. They had less sleep (overall and in REM), lower REM density, and lower spindle activity (12-16 Hz). Applying OCMs to randomized studies with neural outcomes can clarify neural heterogeneity and jumpstart mechanistic research; with further validation they also offer promise for personalized brain-based treatments and interventions.
Collapse
|
17
|
Zilcha-Mano S, Roose SP, Brown PJ, Rutherford BR. A Machine Learning Approach to Identifying Placebo Responders in Late-Life Depression Trials. Am J Geriatr Psychiatry 2018; 26:669-677. [PMID: 29398354 PMCID: PMC5993576 DOI: 10.1016/j.jagp.2018.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/20/2017] [Accepted: 01/04/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite efforts to identify characteristics associated with medication-placebo differences in antidepressant trials, few consistent findings have emerged to guide participant selection in drug development settings and differential therapeutics in clinical practice. Limitations in the methodologies used, particularly searching for a single moderator while treating all other variables as noise, may partially explain the failure to generate consistent results. The present study tested whether interactions between pretreatment patient characteristics, rather than a single-variable solution, may better predict who is most likely to benefit from placebo versus medication. METHODS Data were analyzed from 174 patients aged 75 years and older with unipolar depression who were randomly assigned to citalopram or placebo. Model-based recursive partitioning analysis was conducted to identify the most robust significant moderators of placebo versus citalopram response. RESULTS The greatest signal detection between medication and placebo in favor of medication was among patients with fewer years of education (≤12) who suffered from a longer duration of depression since their first episode (>3.47 years) (B = 2.53, t(32) = 3.01, p = 0.004). Compared with medication, placebo had the greatest response for those who were more educated (>12 years), to the point where placebo almost outperformed medication (B = -0.57, t(96) = -1.90, p = 0.06). CONCLUSION Machine learning approaches capable of evaluating the contributions of multiple predictor variables may be a promising methodology for identifying placebo versus medication responders. Duration of depression and education should be considered in the efforts to modulate placebo magnitude in drug development settings and in clinical practice.
Collapse
Affiliation(s)
| | - Steven P Roose
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY
| | - Patrick J Brown
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY
| | - Bret R Rutherford
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY
| |
Collapse
|
18
|
Promise and Challenges of Using Combined Moderator Methods to Personalize Mental Health Treatment. Am J Geriatr Psychiatry 2018; 26:678-679. [PMID: 29776727 PMCID: PMC6292524 DOI: 10.1016/j.jagp.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 11/21/2022]
|
19
|
Affiliation(s)
- Zachary D. Cohen
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Robert J. DeRubeis
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| |
Collapse
|
20
|
Abstract
UNLABELLED This paper reviews recent research on late-life depression (LLD) pharmacotherapy, focusing on updated information for monotherapy and augmentation treatments. We then review new research on moderators of clinical response and how to use the information for improved efficacy. RECENT FINDINGS A recent review shows that sertraline, paroxetine, and duloxetine were superior to placebo for the treatment of LLD. There is concern that paroxetine could have adverse outcomes in the geriatric population due to anticholinergic properties; however, studies show no increases in mortality, dementia risk, or cognitive measures. Among newer antidepressants, vortioxetine has demonstrated efficacy in LLD, quetiapine has demonstrated efficacy especially for patients with sleep disturbances, and aripiprazole augmentation for treatment resistance in LLD was found to be safe and effective. Researchers have also been identifying moderators of LLD that can guide treatment. Researchers are learning how to associate moderators, neuroanatomical models, and antidepressant response. SSRI/SNRIs remain first-line treatment for LLD. Aripiprazole is an effective and safe augmentation for treatment resistance. Studies are identifying actionable moderators that can increase treatment response.
Collapse
|
21
|
Gebara MA, DiNapoli EA, Kasckow J, Karp JF, Blumberger DM, Lenze EJ, Mulsant BH, Reynolds CF. Specific depressive symptoms predict remission to aripiprazole augmentation in late-life treatment resistant depression. Int J Geriatr Psychiatry 2018; 33:e330-e335. [PMID: 28975710 PMCID: PMC5773368 DOI: 10.1002/gps.4813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/29/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify which specific depressive symptoms predict remission to aripiprazole augmentation in late-life treatment resistant depression. METHODS This is a secondary analysis of data from a late-life treatment resistant depression trial examining the safety and efficacy of aripiprazole augmentation. Participants aged 60 and above were randomized to aripiprazole augmentation (N = 91) versus placebo (N = 90). The main outcome was depression remission. Clinical predictors included individual Montgomery-Asberg Depression Rating Scale (MADRS) item scores categorized as symptomatic (scores >2) or nonsymptomatic (scores ≤2). RESULTS Three MADRS items predicted depression remission with aripiprazole augmentation: symptomatic scores on sleep disturbance and nonsymptomatic scores on apparent sadness and inability to feel. The 2-way and 3-way interaction terms of these MADRS items were not significant predictors of remission; therefore, the models' ability to predict remission was not improved by combining the significant MADRS items. CONCLUSIONS The identification of specific depressive symptoms, which can be clinically assessed, can be used to inform treatment decisions. Older adults with treatment resistant depression that present with sleep disturbances, lack of apparent sadness, or lack of inability to feel should be considered for aripiprazole augmentation.
Collapse
Affiliation(s)
- Marie Anne Gebara
- University of Pittsburgh School of Medicine, Pittsburgh, PA,Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Elizabeth A. DiNapoli
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - John Kasckow
- VA Beckley Healthcare System, Beckley, West Virginia
| | - Jordan F. Karp
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel M. Blumberger
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Eric J. Lenze
- Washington University School of Medicine, St. Louis, MO
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Charles F. Reynolds
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| |
Collapse
|
22
|
Predictors of treatment outcome in depression in later life: A systematic review and meta-analysis. J Affect Disord 2018; 227:164-182. [PMID: 29100149 DOI: 10.1016/j.jad.2017.10.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/13/2017] [Accepted: 10/01/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Predictor analyses of late-life depression can be used to identify variables associated with outcomes of treatments, and hence ways of tailoring specific treatments to patients. The aim of this review was to systematically identify, review and meta-analyse predictors of outcomes of any type of treatment for late-life depression. METHODS Pubmed, Embase, CINAHL, Web of Science and PsycINFO were searched for studies published up to December 2016. Primary and secondary studies reported treatment predictors from randomised controlled trials of any treatment for patients with major depressive disorder aged over 60 were included. Treatment outcomes included response, remission and change in depression score. RESULTS Sixty-seven studies met the inclusion criteria. Of 65 identified statistically significant predictors, only 7 were reported in at least 3 studies. Of these, 5 were included in meta-analyses, and only 3 were statistically significant. Most studies were rated as being of moderate to strong quality and satisfied key quality criteria for predictor analyses. LIMITATIONS The searches were limited to randomised controlled trials and most of the included studies were secondary analyses. CONCLUSIONS Baseline depression severity, co-morbid anxiety, executive dysfunction, current episode duration, early improvement, physical illnesses and age were reported as statistically significant predictors of treatment outcomes. Only the first three were significant in meta-analyses. Subgroup analyses showed differences in predictor effect between biological and psychosocial treatment. However, high heterogeneity and small study numbers suggest a cautious interpretation of results. These predictors were associated with various mechanisms including brain pathophysiology, perceived social support and proposed distinct types of depressive disorder. Further investigation of the clinical utility of these predictors is suggested.
Collapse
|
23
|
Vittengl JR, Clark LA, Thase ME, Jarrett RB. Initial Steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder. Psychiatry Res 2017; 253:174-181. [PMID: 28388454 PMCID: PMC5481171 DOI: 10.1016/j.psychres.2017.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
Responders to acute-phase cognitive therapy (A-CT) for major depressive disorder (MDD) often relapse or recur, but continuation-phase cognitive therapy (C-CT) or fluoxetine reduces risks for some patients. We tested composite moderators of C-CT versus fluoxetine's preventive effects to inform continuation treatment selection. Responders to A-CT for MDD judged to be at higher risk for relapse due to unstable or partial remission (N=172) were randomized to 8 months of C-CT or fluoxetine with clinical management and assessed, free from protocol treatment, for 24 additional months. Pre-continuation-treatment characteristics that in survival analyses moderated treatments' effects on relapse over 8 months of continuation-phase treatment (residual symptoms and negative temperament) and on relapse/recurrence over the full observation period's 32 months (residual symptoms and age) were combined to estimate the potential advantage of C-CT versus fluoxetine for individual patients. Assigning patients to optimal continuation treatment (i.e., to C-CT or fluoxetine, depending on patients' pre-continuation-treatment characteristics) resulted in absolute reduction of relapse or recurrence risk by 16-21% compared to the other non-optimal treatment. Although these novel results require replication before clinical application, selecting optimal continuation treatment (i.e., personalizing treatment) for higher risk A-CT responders may decrease risks of MDD relapse and recurrence substantively.
Collapse
Affiliation(s)
- Jeffrey R. Vittengl
- Department of Psychology, Truman State University, Kirksville, MO, USA,Correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA, 1-660-785-6041, ; or, Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA, 1-214-648-5345.
| | - Lee Anna Clark
- Department of Psychology, University of Notre Dame, Notre Dame, IN, USA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robin B. Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA,Correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA, 1-660-785-6041, ; or, Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA, 1-214-648-5345.
| |
Collapse
|
24
|
Patel K, Abdool PS, Rajji TK, Mulsant BH. Pharmacotherapy of major depression in late life: what is the role of new agents? Expert Opin Pharmacother 2017; 18:599-609. [DOI: 10.1080/14656566.2017.1308484] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Kinjal Patel
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Petal S. Abdool
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Outpatient Geriatric Mental Health Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tarek K. Rajji
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Geriatric Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Benoit H. Mulsant
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| |
Collapse
|
25
|
Wallace ML, McMakin DL, Tan PZ, Rosen D, Forbes EE, Ladouceur CD, Ryan ND, Siegle GJ, Dahl RE, Kendall PC, Mannarino A, Silk JS. The role of day-to-day emotions, sleep, and social interactions in pediatric anxiety treatment. Behav Res Ther 2016; 90:87-95. [PMID: 28013054 DOI: 10.1016/j.brat.2016.12.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 11/22/2016] [Accepted: 12/16/2016] [Indexed: 01/23/2023]
Abstract
Do day-to-day emotions, social interactions, and sleep play a role in determining which anxious youth respond to supportive child-centered therapy (CCT) versus cognitive behavioral therapy (CBT)? We explored whether measures of day-to-day functioning (captured through ecological momentary assessment, sleep diary, and actigraphy), along with clinical and demographic measures, were predictors or moderators of treatment outcome in 114 anxious youth randomized to CCT or CBT. We statistically combined individual moderators into a single, optimal composite moderator to characterize subgroups for which CCT or CBT may be preferable. The strongest predictors of better outcome included: (a) experiencing higher positive affect when with one's mother and (b) fewer self-reported problems with sleep duration. The composite moderator indicated that youth for whom CBT was indicated had: (a) more day-to-day sleep problems related to sleep quality, efficiency, and waking, (b) day-to-day negative events related to interpersonal concerns, (c) more DSM-IV anxiety diagnoses, and (d) college-educated parents. These findings illustrate the value of both day-to-day functioning characteristics and more traditional sociodemographic and clinical characteristics in identifying optimal anxiety treatment assignment. Future studies will need to enhance the practicality of real-time measures for use in clinical decision making and evaluate additional anxiety treatments.
Collapse
Affiliation(s)
- Meredith L Wallace
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15260, USA; Department of Statistics, University of Pittsburgh, 230 South Bouquet Street, Pittsburgh, PA 15260, USA.
| | - Dana L McMakin
- Department of Psychology, Florida International University, 11200 S. W. 8th Street, Miami, FL 33199, USA.
| | - Patricia Z Tan
- Department of Psychiatry, University of California, 757 Westwood Plaza, Los Angeles, CA 90095, USA.
| | - Dana Rosen
- Department of Psychology, University of Pittsburgh, 210 South Bouquet Street, Pittsburgh, PA 15260, USA.
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15260, USA.
| | - Cecile D Ladouceur
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15260, USA.
| | - Neal D Ryan
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15260, USA.
| | - Greg J Siegle
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15260, USA.
| | - Ronald E Dahl
- School of Public Health, University of California, 50 University Hall, Berkeley, CA 94720, USA.
| | - Philip C Kendall
- Department of Psychology, Temple University, 1701 North 13th Street, Philadelphia, PA 19122, USA.
| | - Anthony Mannarino
- Allegheny General Hospital, Four Allegheny Center, Pittsburgh, PA 15212, USA.
| | - Jennifer S Silk
- Department of Psychology, University of Pittsburgh, 210 South Bouquet Street, Pittsburgh, PA 15260, USA.
| |
Collapse
|
26
|
Treatment-Resistant Depression in the Elderly: Diagnostic and Treatment Approaches. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0186-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|