The mechanisms of tolerance in antidepressant action

Symptom Change during Waitlist for Medicated and Nonmedicated Patients with Chronic Depression

INTRODUCTION

Patients seeking psychotherapy often spend time on waitlist (WL), the effect of which is largely unknown. WL patients may forego alternative non-psychotherapeutic assistance and thus do more poorly than had they not been placed on a WL. The course of symptoms might also be influenced by use of antidepressant medication (ADM), an issue that remains unexplored in the literature.

OBJECTIVE

In a naturalistic setting, WL symptom change before inpatient psychotherapy (mean weeks of waiting = 22.6) was assessed in a sample (N = 313) of chronically depressed patients.

METHODS

Using the Beck Depression Inventory-II, patients' symptoms were tracked at assessment, when admitted to treatment (i.e., after WL), at posttreatment and 1-year follow-up. Multilevel growth curve analysis was used to examine waitlist change for the whole sample as well as for ADM users and nonmedicated patients.

RESULTS

Symptoms were reduced significantly from assessment to admittance (Cohen's d = 0.47). Symptoms reduced less for ADM users (d = 0.39) than for nonmedicated patients (d = 0.65).

CONCLUSION

The findings indicate that chronically depressed patients experience a decrease in symptoms during WL, quite likely due to treatment expectations. We discuss whether less symptom improvement for ADM users could be attributed to iatrogenic comorbidity and a higher degree of demoralization in this group.

Adolescent nonpharmacological interventions for early-life stress and their mechanisms

Those with a negative experience of psychosocial stress during the early stage of life not only have a high susceptibility of the psychiatric disorder in all phases of their life span, but they also demonstrate more severe symptoms and poorer response to treatment compared to those without a history of early-life stress. The interventions targeted to early-life stress may improve the effectiveness of treating and preventing psychiatric disorders. Brain regions associated with mood and cognition develop rapidly and own heightened plasticity during adolescence. So, manipulating nonpharmacological interventions in fewer side effects and higher acceptance during adolescence, which is a probable window of opportunity, may ameliorate or even reverse the constantly deteriorating impact of early-life stress. The present article reviews animal and people studies about adolescent nonpharmacological interventions for early-life stress. We aim to discuss whether those adolescent nonpharmacological interventions can promote individuals' psychological health who expose to early-life stress.

What are the treatment remission, response and extent of improvement rates after up to four trials of antidepressant therapies in real-world depressed patients? A reanalysis of the STAR*D study's patient-level data with fidelity to the original research protocol

OBJECTIVE

Reanalyse the patient-level data set of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study with fidelity to the original research protocol and related publications.

DESIGN

The study was open label and semirandomised examining the effectiveness of up to four optimised and increasingly aggressive, antidepressant therapies in depressed adults. Patients who failed to gain adequate relief from their level 1 trial on the SSRI citalopram could receive up to three additional treatment trials in levels 2-4.

SETTING

41 North American psychiatry and primary care treatment centres.

PARTICIPANTS

4041 adults screened positive for major depressive disorder. In contrast to most clinical trials, STAR*D enrolled patients seeking care (vs recruited) and included patients with a wide range of common comorbid medical and psychiatric conditions to enhance the generalisability of findings to real-world clinical practice.

INTERVENTIONS

STAR*D evaluated the relative effectiveness of 13 antidepressants therapies in treatment levels 2-4 for depressed patients who failed to gain adequate benefit from their level 1 medication trial.

MAIN OUTCOME MEASURES

According to the STAR*D protocol, the primary outcome was remission, defined as a score <8 on the blinded Hamilton Rating Scale for Depression (HRSD). Response was a secondary outcome defined as ≥50% reduction in HRSD scores. STAR*D's protocol specifically excluded all non-blinded clinic-administered assessments from use as research outcome measures.

RESULTS

STAR*D investigators did not use the protocol-stipulated HRSD to report cumulative remission and response rates in their summary article and instead used a non-blinded clinic-administered assessment. This inflated their report of outcomes, as did their inclusion of 99 patients who scored as remitted on the HRSD at study outset as well as 125 who scored as remitted when initiating their next-level treatment. These patients should have been excluded from data analysis. In contrast to the STAR*D-reported 67% cumulative remission rate after up to four antidepressant treatment trials, the rate was 35.0% when using the protocol-stipulated HRSD and inclusion in data analysis criteria.

CONCLUSION

STAR*D's cumulative remission rate was approximately half of that reported.

Infrequent Intranasal Oxytocin Followed by Positive Social Interaction Improves Symptoms in Autistic Children: A Pilot Randomized Clinical Trial

INTRODUCTION

There are currently no approved drug interventions for social behavior dysfunction in autism spectrum disorder (ASD). Previous trials investigating effects of daily intranasal oxytocin treatment have reported inconsistent results and have not combined it with positive social interaction. However, in two preclinical studies we established that treatment every other day rather than daily is more efficacious in maintaining neural and behavioral effects by reducing receptor desensitization.

OBJECTIVE

We aimed to establish whether a 6-week intranasal oxytocin compared with placebo treatment, followed by a period of positive social interaction, would produce reliable symptom improvements in children with ASD.

METHODS

A pilot double-blind, randomized, crossover design trial was completed including 41 children with ASD aged 3-8 years. Primary outcomes were the Autism Diagnostic Observation Schedule-2 (ADOS-2) and social responsivity scale-2 (SRS-2). Secondary measures included cognitive, autism- and caregiver-related questionnaires, and social attention assessed using eye-tracking.

RESULTS

Significant improvements were found for oxytocin relative to placebo in primary outcome measures (total ADOS-2 and SRS-2 scores, ps < 0.001) and in behavioral adaptability and repetitive behavior secondary measures. Altered SRS-2 scores were associated with increased saliva oxytocin concentrations. Additionally, oxytocin significantly increased time spent viewing dynamic social compared to geometric stimuli and the eyes of angry, happy, and neutral expression faces. There were no adverse side effects of oxytocin treatment.

CONCLUSIONS

Overall, results demonstrate that a 6-week intranasal oxytocin treatment administered every other day and followed by positive social interactions can improve clinical, eye tracking, and questionnaire-based assessments of symptoms in young autistic children.

A Focus on Abuse/Misuse and Withdrawal Issues with Selective Serotonin Reuptake Inhibitors (SSRIs): Analysis of Both the European EMA and the US FAERS Pharmacovigilance Databases

Despite increasing reports, antidepressant (AD) misuse and dependence remain underestimated issues, possibly due to limited epidemiological and pharmacovigilance evidence. Thus, here we aimed to determine available pharmacovigilance misuse/abuse/dependence/withdrawal signals relating to the Selective Serotonin Reuptake Inhibitors (SSRI) citalopram, escitalopram, paroxetine, fluoxetine, and sertraline. Both EudraVigilance (EV) and Food and Drug Administration-FDA Adverse Events Reporting System (FAERS) datasets were analysed to identify AD misuse/abuse/dependence/withdrawal issues. A descriptive analysis was performed; moreover, pharmacovigilance measures, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC), and the empirical Bayesian geometric mean (EBGM) were calculated. Both datasets showed increasing trends of yearly reporting and similar signals regarding abuse and dependence. From the EV, a total of 5335 individual ADR reports were analysed, of which 30% corresponded to paroxetine (n = 1592), 27% citalopram (n = 1419), 22% sertraline (n = 1149), 14% fluoxetine (n = 771), and 8% escitalopram (n = 404). From FAERS, a total of 144,395 individual ADR reports were analysed, of which 27% were related to paroxetine, 27% sertraline, 18% citalopram, 16% fluoxetine, and 13% escitalopram. Comparing SSRIs, the EV misuse/abuse-related ADRs were mostly recorded for citalopram, fluoxetine, and sertraline; conversely, dependence was mostly associated with paroxetine, and withdrawal to escitalopram. Similarly, in the FAERS dataset, dependence/withdrawal-related signals were more frequently reported for paroxetine. Although SSRIs are considered non-addictive pharmacological agents, a range of proper withdrawal symptoms can occur well after discontinuation, especially with paroxetine. Prescribers should be aware of the potential for dependence and withdrawal associated with SSRIs.

The effects of drug safety warnings on drug sales and share prices

Current regulations require that when seeking approval for new drugs, pharmaceutical companies must demonstrate their short- but not long-term safety and efficacy. Instead, post-approval, clinicians report adverse reactions to regulators, who may issue additional safety warnings. We investigate the incentives this creates for pharmaceutical companies to seek approval for new drugs with unknown long-term effects. We first construct models predicting that (1) long-run effects can be reasonably approximated from observational follow-up of short-term randomized control trials, and (2) companies will trade-off short-term sales against possible later adverse demand effects. We then test whether regulator warnings over diabetic, analgesic, analeptic, or psychoanaleptic drugs sold in the US and UK hospital and retail sectors affect the sales of individual drugs or the share prices of companies that sell them. With some exceptions, we find that pharmaceutical companies generally face no adverse market reaction in sales or share price from newly issued warnings in these four drug categories.

More treatment but no less depression: The treatment-prevalence paradox

Treatments for depression have improved, and their availability has markedly increased since the 1980s. Mysteriously the general population prevalence of depression has not decreased. This "treatment-prevalence paradox" (TPP) raises fundamental questions about the diagnosis and treatment of depression. We propose and evaluate seven explanations for the TPP. First, two explanations assume that improved and more widely available treatments have reduced prevalence, but that the reduction has been offset by an increase in: 1) misdiagnosing distress as depression, yielding more "false positive" diagnoses; or 2) an actual increase in depression incidence. Second, the remaining five explanations assume prevalence has not decreased, but suggest that: 3) treatments are less efficacious and 4) less enduring than the literature suggests; 5) trial efficacy doesn't generalize to real-world settings; 6) population-level treatment impact differs for chronic-recurrent versus non-recurrent cases; and 7) treatments have some iatrogenic consequences. Any of these seven explanations could undermine treatment impact on prevalence, thereby helping to explain the TPP. Our analysis reveals that there is little evidence that incidence or prevalence have increased as a result of error or fact (Explanations 1 and 2), and strong evidence that (a) the published literature overestimates short- and long-term treatment efficacy, (b) treatments are considerably less effective as deployed in "real world" settings, and (c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases. Collectively, these a-c explanations likely account for most of the TPP. Lastly, little research exists on iatrogenic effects of current treatments (Explanation 7), but further exploration is critical.

An Oppositional Tolerance Account for Potential Cognitive Deficits Caused by the Discontinuation of Antidepressant Drugs

Depression is the leading cause of disability worldwide, making antidepressant drugs the most used psychiatric drugs in the USA. Withdrawal effects and rebound symptoms frequently occur after the reduction and/or discontinuation of these drugs. Although these phenomena have been investigated with respect to the clinical symptomatology, no studies have systematically investigated the effects of withdrawal/rebound on general cognition. We present a novel framework based on the idea of allostatic adaptation, which allows to predict how different antidepressants likely impair different cognitive processes as a result of withdrawal and rebound effects. This framework relies on the assumptions that the type of cognitive impairments evoked by an antidepressant is determined by the targeted neurotransmitter systems, while the severity of deficits depends on its half-life. Our model predicts that the severity of detrimental cognitive withdrawal and rebound effects increases with a shorter half-life of the discontinued antidepressant drug. It further proposes drug-specific effects: antidepressants mainly targeting serotonin should primarily impair aversive and emotional processing, those targeting norepinephrine should impair the processing of alerting signals, those targeting dopamine should impair motivational processes and reward processing, and those targeting acetylcholine should impair spatial learning and memory. We hope that this framework will motivate further research to better understand and explain cognitive changes as a consequence of antidepressant discontinuation.

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015;84(2):63-71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be short-lived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

Depression in disabling medical conditions - current perspectives

Chronic diseases commonly entail disability and are highly comorbid with mental health problems, particularly depression. Prevalence of depression across different disabling conditions affecting adult patients, as well as risk factors for depression in these patient groups are reviewed in the current work, with a particular focus on the literature published in the past 5 years. The prevalence of depression in disabling conditions is higher than in the general population and is associated with different factors. Examples of disease-specific factors include neurological implications of stoke, diabetic related conditions (e.g. amputation), limitations imposed by vision loss caused by age-related eye diseases, fatigue in rheumatoid arthritis, and pain in cancer. Common factors identified across different conditions include pre-morbid depression, history of mental health problems, poor social support, disease-related disability, multi-morbidity, and less adaptive coping strategies. We also reviewed studies suggesting a potential bidirectional relationship between depression and chronic disease, particularly for stroke, cardiovascular disease, diabetes, and potential factors mediating that relationship. Current findings suggested that long-term depression might be associated with an increased risk of subsequent physical health problems, although the nature of that relationship and its underlying mechanisms are still unclear.

Exercise and fluoxetine treatment during adolescence protect against early life stress-induced behavioral abnormalities in adult rats

Depression is a psychiatric disorder with several comorbidities that has a complicated pathophysiology. Multiple mechanisms such as abnormal hypothalamic-pituitary adrenal (HPA) axis activity, neurotransmission (namely serotonin), and immune-inflammatory responses are involved in the pathophysiology of disease. In this study, we hypothesized that applying exercise (running wheel (RW) and treadmill (TM)) or fluoxetine (FLX) during adolescence could protect adult rats against the negative impact of early-life stress. To do this, we applied maternal separation stress (MS) to neonatal rats from postnatal day (PND) 2 to 14 and at PND 28, rats were divided into 8 experimental groups and were subjected to TM or RW or FLX treatment. After four weeks of physical activity or FLX treatment, at PND 64, behaviors were assessed by applying forced swimming test, sucrose preference test, open-field test, and elevated plus maze test. Serum cortiscosterone (CORT) levels and expression of genes associated with inflammatory factors (Il1β, Hmgb1, and Il6) and serotonergic systems (5-ht2c and 5-ht3a) were studies in the hippocampus (HIPP) and prefrontal cortex (PFC). Our results revealed that RW and FLX treatment during adolescence are capable of attenuating MS-induced depressive- and anxiety-like disorders in adult male rats. These effects were accompanied by the normalization of both serum CORT and the expression of genes in the HIPP and PFC. TM exercise in adolescence showed anxiolytic effects but failed to produce antidepressant-like effects. Results of this study suggest that voluntary physical activity during adolescence can reduce the negative effects of early-life stress through different mechanisms.

Well-being Therapy in Depressive Disorders

A specific brief psychotherapeutic intervention aimed at empowering psychological well-being, the so-called Well-Being Therapy (WBT), has been manualized in 2016 by Giovanni Fava and has shown to be effective in randomized controlled trials. WBT is based on the multidimensional model of psychological well-being developed by Marie Jahoda which encompasses environmental mastery, personal growth, purpose in life, autonomy, self-acceptance, positive relations with others, and balance of psychic forces. WBT aims at promoting the achievement of an optimal-balanced functioning between the dimensions of psychological well-being, and such a balance is subsumed under the rubric of euthymia. There are evidences that WBT may be a suited clinical approach for second- or third-line treatment of depressive disorders with particular reference to decreasing vulnerability to relapse and modulating psychological well-being and mood. It has been also proposed a role of WBT in depressive disorders in clinical conditions such as treatment resistance, loss of antidepressant clinical efficacy, persistent post-withdrawal disorders, trauma exposure, and medical disease comorbidity. The present chapter provides an overview of the possible applications of WBT as treatment of depressive disorders.

The role of Facebook groups in the management and raising of awareness of antidepressant withdrawal: is social media filling the void left by health services?

BACKGROUND

Antidepressant withdrawal is experienced by about half of people who try to reduce or come off their medication. It can be a debilitating, long lasting process. Many clinicians misdiagnose or minimise symptoms, inadvertently prolonging suffering. Most are unable to help patients safely taper off. There has been little research into the peer support communities that are playing an increasingly important role in helping people withdraw from psychiatric medications.

METHODS

To illustrate the growth and activities of Facebook withdrawal groups, we examined 13 such groups. All were raising awareness of, and supporting individuals tapering off, antidepressants and were followed for 13 months. A further three groups were added for the last 5 months of the study.

RESULTS

In June 2020, the groups had a total membership of 67,125, of which, 60,261 were in private groups. The increase in membership for the 13 groups over the study period was 28.4%. One group was examined in greater detail. Group membership was 82.5% female, as were 80% of the Administrators and Moderators, all of whom are lay volunteers. Membership was international but dominated (51.2%) by the United States (US). The most common reason for seeking out this group was failed clinician-led tapers.

DISCUSSION

The results are discussed in the context of research on the prevalence, duration and severity of antidepressant withdrawal. We question why so many patients seek help in peer-led Facebook groups, rather than relying on the clinicians that prescribed the medications. The withdrawal experiences of tens of thousands of people remain hidden in these groups where they receive support to taper when healthcare services should be responsible. Further research should focus on the methods of support and tapering protocols used in these groups to enable improved, more informed support by clinicians. Support from Governments and healthcare agencies is also needed, internationally, to address this issue.

Relapse prevention in recurrent major depressive disorder. A comparison of different treatment options based on clinical experience and a critical review of the literature

BACKGROUND

Reducing the risk of relapses is a critical component of major depressive disorders treatment. Guidelines suggest maintenance with antidepressant drugs in recurrent depression, but this solution has recently been questioned.

OBJECTIVE

The aim of this article is to provide a critical review of the literature of the main treatment options currently available to prevent relapse and recurrence in depression.

METHODS

We compared long-term antidepressant therapy (i.e., indefinite maintenance of antidepressant), intermittent antidepressant therapy (i.e., use of antidepressants mainly limited to the acute phases), use of psychotherapy in the sequential model (i.e., pharmacotherapy in the acute phase and psychotherapy in the residual phase).

RESULTS

We argue that the same solution may not apply to all patients and question the feasibility of a single course of treatment in the setting of complex disorders that are encountered in practice. The clinician should weigh advantages and disadvantages in the individual case.

CONCLUSIONS

The sequential model appears to be particularly indicated in recurrent depression. KEY POINTS Relapse is a major challenge of depressive disorders treatment Treatment options currently available include long-term antidepressants, intermittent antidepressants, addition of psychotherapy to pharmacotherapy in the sequential model Maintenance with antidepressants in recurrent depression has recently been questioned The sequential model appears to be particularly indicated in recurrent depression.

Can loss of agency and oppositional perturbation associated with antidepressant monotherapy and low-fidelity psychological treatment dilute the benefits of guideline-consistent depression treatment at the population level?

Despite major expansions of evidence-based treatments of common mental disorders in recent decades, especially antidepressant medication, the point prevalence of depression has not decreased; instead it probably increased in young adults. We question whether antidepressants (AD)-monotherapy and low-fidelity-to-guideline psychological treatment (PT) might have no effect or even adverse effects in some patients and contexts that dilute the benefits of treatment at the population level, making it harder for population-based studies to detect treatment-driven prevalence reductions. Randomized Clinical Trial (RCT)s have not identified these effects because AD-monotherapy and low-fidelity PT are uncommon in RCTs where treatment protocols are specified and carefully monitored, unlike treatment in real-world settings. Second, RCTs may have missed the bigger picture of ultimate outcomes due to too short follow-ups. We elaborate two mechanisms through which AD-monotherapy and low-fidelity PT could produce adverse effects on long-term illness course. Both mechanisms are speculative and we outline how to test.

Criterion-related validity in a sample of migraine outpatients: the diagnostic criteria for psychosomatic research

OBJECTIVE

The Diagnostic Criteria for Psychosomatic Research (DCPR) are those of psychosomatic syndromes that did not find room in the classical taxonomy. More recently, the DCPR were updated, called DCPR-revised (DCPR-R). The present study was conducted to test the criterion-related validity of the DCPR-R.

METHODS

Two hundred consecutive subjects were enrolled at the Headache Center of Careggi University Hospital (Italy): 100 subjects had a diagnosis of chronic migraine (CM) and 100 had a diagnosis of episodic migraine (EM). Participants received a clinical assessment, which included the DCPR-revised Semi-Structured Interview (DCPR-R SSI), the Structured Clinical Interview for DSM-5 (SCID-5), and the psychosocial index (PSI).

RESULTS

Forty-seven subjects (23.5%) had at least one DSM-5 diagnosis: major depressive disorder (8.5%; n = 17) and agoraphobia (7.5%; n = 15) were the most frequent. One hundred and ten subjects (55%) reported a DCPR-R diagnosis: allostatic overload (29%; n = 58) and type A behavior (10.5%; n = 21) were the most frequent. When the incremental validity of the DCPR system over the DSM system was tested using PSI subscales as the criterion variable, the DCPR-R increased up to 0.11-0.24 the amount of explained variance. Subjects with at least one DCPR-R diagnosis showed lower PSI well-being scores (p = .001), higher PSI stress scores (p < .001), and higher PSI psychological distress scores (p = .008) than subjects without a DCPR-R diagnosis.

CONCLUSION

The DCPR-R showed a good criterion-related validity in migraine outpatients. Thus, they might be implemented, together with the DSM-5, in the assessment of migraine subjects.

Antidepressant Withdrawal and Rebound Phenomena

BACKGROUND

Antidepressants are among the most commonly prescribed drugs worldwide. They are often discontinued, frequently without the knowledge of the prescribing physician. It is, therefore, important for physicians to be aware of the withdrawal and rebound phenomena that may arise, in order to prevent these phenomena, treat them when necessary, and counsel patients appropriately.

METHODS

This review is based on a comprehensive, structured literature search on antidepressant withdrawal phenomena that we carried out in the CENTRAL, PubMed (Medline), and Embase databases. We classified the relevant publications and reports by their methodological quality.

RESULTS

Out of a total of 2287 hits, there were 40 controlled trials, 38 cohort studies and retrospective analyses, and 271 case reports that met the inclusion criteria. Withdrawal manifestations are usually mild and self-limiting; common ones include dizziness, headache, sleep disturbances, and mood swings. More serious or pro- longed manifestations rarely arise. There is an increased risk with MAO inhibitors, tricyclic antidepressants, venlafaxine, and paroxetine; on the other hand, for agome- latine and fluoxetine, abrupt discontinuation seems to be unproblematic. There is also some evidence of rebound phenomena, i.e., of higher relapse rates or especially severe relapses of depression after the discontinuation of an anti- depressant.

CONCLUSION

A robust evidence base now indicates that there can be acute with- drawal phenomena when antidepressants are discontinued. Putative rebound phenomena have not been adequately studied to date. It is recommended that antidepressants should be tapered off over a period of more than four weeks.

How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding

The aim of this article is to discuss the validity of relapse prevention trials and the issue of withdrawal confounding in these trials. Recommendations for long-term antidepressant treatment are based almost exclusively on discontinuation trials. In these relapse prevention trials, participants with remitted depression are randomised either to have the antidepressant abruptly discontinued and replaced by inert placebo or to continue active treatment. The drug-placebo difference in relapse rates at the end of the maintenance phase is then interpreted as a prophylactic drug effect. These trials consistently produce remarkable benefits for maintenance treatment. However, the internal validity of this trial protocol is compromised, as research has shown that abruptly stopping antidepressants can cause severe withdrawal reactions that lead to (or manifest as) depression relapses. That is, there is substantial withdrawal confounding in discontinuation trials, which renders their findings uninterpretable. It is not clear to what degree the drug-placebo separation in relapse prevention (discontinuation) trials is due to withdrawal reactions, but various estimations suggest that it is presumably the majority. A review of findings based on other methodologies, including real-world long-term effectiveness trials like STAR*D and various naturalistic cohort studies, do not indicate that antidepressants have considerable prophylactic effects. As absence of evidence does not imply evidence of absence, no definitive conclusions can be drawn from the literature. To enable a thorough risk-benefit evaluation, real-world effectiveness trials should not only focus on relapse prevention, but also assess antidepressants' long-term effects on social functioning and quality of life. Thus far, reliable long-term data on these outcome domains are lacking.

Factors associated with response after deep transcranial magnetic stimulation in a real-world clinical setting: Results from the first 40 cases of treatment-resistant depression

Background:

Deep transcranial magnetic stimulation (dTMS) has been sanctioned by the United States Food and Drug Administration for treatment-resistant depression. In a retrospective cohort study, we evaluated response and effectiveness of dTMS in real-world practice, as an add-on treatment for resistant depression.

Methods:

Forty adult outpatients suffering from depression, all taking psychiatric medications, underwent 20 dTMS treatments over a 4–6 week period. At baseline (T0), visit 10 (T1), and visit 20 (T2), the Clinical Global Impression-Severity (CGI-S) scale was administered, and the Clinical Global Impression Improvement (CGI-I) scale was completed at T1 and T2; the Hamilton Depression Rating Scale (HDRS-21) was administrated at T0 and T2 only. The patients also completed the Quick Inventory of Depressive Symptoms–Self-Report (QIDS-SR) at T0, T1, and T2.

Results:

Depressive symptoms (HDRS-21 total score) decreased significantly following treatment. The HDRS total score decreased from an average of 21.22 (± 6.09) at T0, to 13.95 (± 7.24) at T2. Correspondingly, at T2, 32.5% were responders to the treatment and 20% were in remission, based on the HDRS-21. Treatment was well tolerated, with a discontinuation rate of 7.5%. While depressive symptoms at baseline did not predict remission/response at T2, higher HDRS scores at T0 were associated with a larger decrease in depressive symptoms during the study.

Conclusions:

Significant antidepressant effects were seen following 20 dTMS treatments, given as augmentation to ongoing medications in treatment-resistant depression. The findings suggest that among patients with TRD, the severity of the depressive episode (and not necessarily the number of failed antidepressant medication trials) is associated with a positive therapeutic effect of dTMS. Hence, the initial severity of the depressive episode may guide clinicians in referring patients for dTMS.

Prior Antidepressant Treatment Trials May Predict a Greater Risk of Depressive Relapse During Antidepressant Maintenance Therapy

BACKGROUND

We examined the influence of prior antidepressant treatment trials on the likelihood of depressive relapse, and time to depressive relapse, during maintenance therapy of bipolar II disorder in treatment-responsive subjects who had recovered from a major depressive episode.

METHODS

Data were derived from a prospective, randomized, double-blind trial of 148 adult subjects with bipolar II major depressive episode who were initially administered open-label fluoxetine monotherapy for 12 weeks. Remitters with a final Hamilton Rating Scale for Depression score of 8 or lower were then randomized to continuation therapy with either fluoxetine (n = 28), lithium (n = 26), or placebo (n = 27) for 50 additional weeks.

RESULTS

An increase in the number of prior antidepressant treatment trials was significantly associated with a greater likelihood of depressive relapse for all treatment conditions taken together [odds ratio (OR) = 1.42, z = 2.49, P = 0.01] and for the 2 active treatment conditions together (OR = 1.51, z = 2.28, P = 0.02). An increase in the number of prior antidepressant trials was also associated with a trend-level shortening in the time to relapse for all treatment conditions taken together (hazard ratio = 1.15; confidence interval, 0.99-1.35; P = 0.07) and a significantly shorter time to relapse for subjects in the 2 active treatment conditions (hazard ratio = 1.30; confidence interval, 1.05-1.62; P = 0.02).

CONCLUSIONS

These findings support prior evidence of a negative influence of the number of prior antidepressant treatment trials on the likelihood of response and suggest that the number of prior antidepressant trials may also be associated with a greater odds of depressive relapse, and a shorter time to relapse, during antidepressant maintenance therapy in recovered depressed subjects with bipolar II disorder.

May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance

In recent years there has been a considerable debate on antidepressant drugs. Continued drug treatment with antidepressant medications may stimulate processes that run counter to the initial acute effects of a drug. The oppositional model of tolerance may explain loss of treatment efficacy during maintenance treatment and the fact that some side effects tend to occur only after a certain time. These processes may also direct the illness into a treatment-unresponsive course, including manifestations of bipolar disorder or paradoxical reactions. When drug treatment ends, oppositional processes no longer encounter resistance, resulting in potential onset of new withdrawal symptoms, persistent post-withdrawal disorders, hypomania, and resistance to treatment if it is reinstituted. In all these cases, antidepressant medications may constitute a form of iatrogenic comorbidity, which increases chronicity and vulnerability to depressive episodes. Antidepressant medications are essential drugs for the treatment of major depressive episodes. They are less likely, however, to provide protection for relapse prevention. Current prescription practices need to be reformulated in light of consideration of vulnerabilities and adverse effects of treatment. The oppositional model of tolerance provides a conceptual framework for weighing all these elements in the individual case. The model does not appear to apply to all patients who undergo treatment with AD, but only to a part of them. Studying the variables that are associated with such occurrence in certain patients and not in others would be one of the most important tasks of current therapeutic research. Current diagnostic systems in psychiatry do not consider the iatrogenic components of psychopathology, and can be applied to only patients who are drug free. They are suited for a patient who no longer exists: most of the cases that are seen in psychiatric clinical practice receive psychotropic drugs and such treatment is likely to affect prognosis and treatment choices.

Withdrawal effects confounding in clinical trials: another sign of a needed paradigm shift in psychopharmacology research

Randomized controlled trials' ability to produce evidence useful for people to decide whether to take, continue taking, or stop taking psychotropic drugs has been intensely critiqued, along with the trials' commercial, ideological, and regulatory contexts. This article applies the critique to the topic of withdrawal effects confounding the outcomes of relapse-prevention trials where prescribed psychotropic drugs are discontinued. Until recently, the complexity and reach of withdrawal and post-withdrawal effects were neglected by mainstream psychiatry, but not by lay users of prescribed psychotropics. This article discusses withdrawal effects as part of the pharmacology of psychotropic drugs but shaped by psychosocial factors, and possibly shaping the presentation of psychological distress generally. It outlines biases and misconceptions in assumptions, design, and reporting of general efficacy trials and findings from a recent review of 80 discontinuation trials. In theory, relapse-prevention trials are tautological and exaggerate efficacy. In publications, they pay little attention to the central feature of their design, favor abrupt or rapid discontinuations, do not attend to environmental factors, and provide insufficient data to allow re-analyses. Thus, relapse-prevention RCTs likely confound the detection of their main outcome of interest: "relapse." Using slower tapers, active placebo controls, and specific covariates in analyses would reduce the risk of withdrawal confounding, and better reporting would reduce the opaqueness of trials. The crisis in psychopharmacology is fueled partly by the disconnect between claims of therapeutic efficacy from so-called best-evidence methods despite unchanging population-level indicators of psychiatric sickness. Only by "stacking the deck" against trial sponsors' hoped-for outcomes can psychopharmacology trials regain scientific credibility.

Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum

BACKGROUND

Protracted withdrawal syndrome (PWS) after stopping antidepressants (frequently also referred to as post-acute withdrawal syndrome or PAWS) has been described in a few case reports. However, a detailed quantitative analysis of specific symptom manifestations in antidepressant PWS is still lacking.

METHODS

We extracted patient narratives from a large English-language internet forum SurvivingAntidepressants.org, a peer support site concerned about withdrawal from antidepressants. PWS was ascertained based on diagnostic criteria proposed by Chouinard and Chouinard, specifically ⩾6 months of continuous antidepressant use, with emergence of new and/or more intense symptoms after discontinuation that last beyond the initial 6 weeks of acute withdrawal. We assessed medication history, outcome of PWS, and the prevalence of specific symptoms.

RESULTS

In total, n = 69 individual reports of protracted withdrawal were selected for analysis. At time of the subjects' most recent reports, duration of PWS ranged from 5 to 166 months, mean = 37 months, median = 26 months. Length of time on the antidepressant causing protracted withdrawal ranged from 6 to 278 months, mean = 96 months, and median = 79 months. Throughout the withdrawal experience, affective symptoms, mostly anxiety, depression, emerging suicidality and agitation, were reported by 81%. Somatic symptoms, mostly headache, fatigue, dizziness, brain zaps, visual changes, muscle aches, tremor, diarrhea, and nausea were reported by 75%. Sleep problems (44%) and cognitive impairments (32%) were mentioned less frequently. These broad symptom domains were largely uncorrelated.

CONCLUSION

PWS or PAWS from antidepressants can be severe and long-lasting, and its manifestations clinically heterogeneous. Long-term antidepressant exposure may cause multiple body system impairments. Although both somatic and affective symptoms are frequent, they are mostly unrelated in terms of occurrence. Proper recognition and detection of PWS thus requires a comprehensive assessment of medication history, duration of the withdrawal syndrome, and its various somatic, affective, sleep, and cognitive symptoms.

Recurrent Episodes of Paraphilic Behavior Possibly Associated With Olanzapine and Aripiprazole Treatment in a Patient With Schizophrenia

BACKGROUND

Hypersexual and paraphilic disorders have been frequently associated with concomitant psychiatric disorders, including schizophrenia. A growing number of published cases has recently indicated that hypersexual behavior may also arise in conjunction with treatment with second-generation antipsychotics. Although hypersexuality has been acknowledged as a possible side effect of antipsychotic treatment with partial dopamine agonists, including aripiprazole, only very few cases of olanzapine-associated hypersexuality have been reported in the literature.

CASE PRESENTATION

A 29-year-old man presented with delusions of persecution and reference, auditory hallucinations, and negative symptoms, and was diagnosed with paranoid-hallucinatory schizophrenia. One and a half months after initiation of antipsychotic treatment with olanzapine, he developed compulsive sexual behavior and paraphilia, without signs of akathisia. After olanzapine discontinuation, a full remission of the hypersexual behavior was noted within one week, and treatment was switched to risperidone. Due to hyperprolactinemia, adjunct treatment with low-dose aripiprazole was initiated and a severe recurrence of identical hypersexual behavior occurred. The hypersexual behavior resolved completely within a week after aripiprazole discontinuation.

CONCLUSION

This case illustrates that hypersexuality may be a rare adverse effect of treatment with second-generation antipsychotics. Although aripiprazole is a drug with a well-established risk for hypersexuality, the question of whether a causal association between hypersexuality and olanzapine exists remains currently unresolved. As the currently limited amount of available evidence precludes any definitive conclusions, additional research is warranted to delineate the possible neurobiological substrates of hypersexual and paraphilic disorders in patients treated with second-generation antipsychotics.

How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication

Coming off psychotropic drugs can cause physical as well as mental withdrawal, resulting in failed withdrawal attempts and unnecessary long-term drug use. The first reports about withdrawal appeared in the 1950s, but although patients have been complaining about psychotropic withdrawal problems for decades, the first tentative acknowledgement by psychiatry only came in 1997 with the introduction of the 'antidepressant-discontinuation syndrome'. It was not until 2019 that the UK Royal College of Psychiatrists, for the first time, acknowledged that withdrawal can be severe and persistent. Given the lack of a systematic professional response, over the years, patients who were experiencing withdrawal started to work out practical ways to safely come off medications themselves. This resulted in an experience-based knowledge base about withdrawal which ultimately, in The Netherlands, gave rise to the development of person-specific tapering medication (so-called tapering strips). Tapering medication enables doctors, for the first time, to flexibly prescribe and adapt the medication required for responsible and person-specific tapering, based on shared decision making and in full agreement with recommendations in existing guidelines. Looking back, it is obvious that the simple practical solution of tapering strips could have been introduced much earlier, and that the traditional academic strategy of comparisons from randomised trials is not the logical first step to help individual patients. While randomised controlled trials (RCTs) are the gold standard for evaluating interventions, they are unable to accommodate the heterogeneity of individual responses. Thus, a more individualised approach, building on RCT knowledge, is required. We propose a roadmap for a more productive way forward, in which patients and academic psychiatry work together to improve the recognition and person-specific management of psychotropic drug withdrawal.

What are the chances for personalised treatment with antidepressants? Detection of patient-by-treatment interaction with a variance ratio meta-analysis

OBJECTIVES

To investigate if the treatment effect of antidepressants in patients with depression substantially varies in each patient (patient-by-treatment interaction or treatment heterogeneity), a necessary but largely unexplored prerequisite of personalised antidepressant treatment.

DESIGN

Meta-analytic variance comparison of treatment outcome between drug arms and placebo arms of clinical trials, based on the assumption that patient-by-treatment interaction should lead to larger variances in drug arms than placebo arms. To put the results into context, we run simple simulations, assuming different definitions and rates of those who respond especially well to antidepressants.

DATA SOURCES

163 randomised, placebo-controlled trials (51 396 patients) with complete results for pre-post differences, selected from a recently published systematic review.

ANALYSIS

Variance ratios (VRs) and coefficients of variance ratios (CVRs) of individual trials were meta-analytically combined. The analysis was repeated for classes of antidepressants and specific antidepressants.

RESULTS

VRs (VR=1.01, CI 0.99 to 1.02) and CVRs (CVR=0.82, CI 0.80 to 0.84) of the antidepressant-treatment arms were comparable or smaller than in placebo arms. Similar results were observed for classes of antidepressants and for specific antidepressants. Our simulation analysis confirmed that equal VRs can only be obtained if they are not more than a few patients who respond slightly above average.

CONCLUSIONS

The lack of increased treatment-outcome variance in the antidepressants versus placebo groups in randomised controlled trials indicates that no or only very small subgroups of patients respond particularly well to antidepressants. Thus, the scope for personalised treatment with antidepressants seems to be limited.

Long-term outcomes of trials in the National Institute for Health and Care Excellence depression guideline

The forthcoming National Institute for Health and Care Excellence depression guideline reviews short-term outcomes for long-term depression. We present effect sizes for long-term outcomes in trials that report these data. Psychological therapies become more effective, whereas antidepressants become less effective over the long term. We review other forms of longitudinal research that support these findings.

The Emerging Role of Clinical Pharmacopsychology

Clinical pharmacopsychology is an area of clinical psychology that is concerned with the application of clinimetric methods to the assessment of psychotropic effects of drugs on psychological functioning, and the interaction of such drugs with specific or non-specific treatment ingredients. Clinical pharmacopsychology derives its data from observational and controlled studies on clinical populations and refers to the therapeutic use of medical drugs, not to the effects of substances used for other purposes.

Domains and operational settings of clinical pharmacopsychology are illustrated.

The domains of clinical pharmacopsychology extend over several areas of application which encompass the psychological effects of psychotropic drugs (with particular emphasis on subclinical changes), the characteristics that predict responsiveness to treatment, the vulnerabilities induced by treatment (i.e., side effects, behavioral toxicity, iatrogenic comorbidity), and the interactions between drug therapy and psychological variables. A service for clinical pharmacopsychology is here proposed as an example of the innovative role of clinical psychology in medical settings.

Clinical pharmacopsychology offers a unifying framework for the understanding of clinical phenomena in medical and psychiatric settings. Its aim is to provide a comprehensive assessment of the clinical important changes that are concerned with wanted and expected treatment effects; treatment-induced unwanted side effects; and the patient's own personal experience of a change in terms of well-being and/or quality of life. It is now time to practice clinical pharmacopsychology, creating ad hoc services in Europe.

Clinical pharmacopsychology assesses the effects of medications on psychological functioning

Since clinical psychologists visit medicated patients, a comprehensive clinical evaluation is crucial

Vulnerabilities induced by psychotropic drugs are an important area of application of clinical pharmacopsychology

Withdrawal Confounding in Randomized Controlled Trials of Antipsychotic, Antidepressant, and Stimulant Drugs, 2000-2017

BACKGROUND

Results of relapse prevention randomized controlled trials (RCTs) which discontinue psychotropic drug treatment from some participants may be confounded by drug withdrawal symptoms. We test for the confound by calculating whether ≥50% of the difference in relapse risk between drug-discontinued and drug-maintained groups is present at discontinuation time points (DCTs) with "short" and "long" assumptions regarding onset and duration of withdrawal symptoms.

METHODS

In eligible RCTs of antidepressants, antipsychotics, and stimulants from 2000 to 2017 (n = 30) selected from a systematic review, differences in relapse risk were examined by arithmetic and graphical comparison of mean behavioral scores or survival plots.

RESULTS

Only 14 studies (46.6%) with 15 analyses of relapse risk provided sufficient data. Under short and long DCTs, 9 of 13 (69.2%) and 7 of 9 (77.8%) interpretable analyses, respectively, suggested a withdrawal confound. The proportion of endpoint placebo-maintenance group difference present by the DCT averaged 69.1% (range, 58.7-148.0%, n = 13) for short DCT assumptions, and 79.0% (range, 51.5-183.3%, n = 9) under long DCTs. One study (3.33%) controlled for withdraw al effects, and 1 yielded inconclusive results.

CONCLUSIONS

These results support suggestions that withdrawal symptoms confound the results of relapse prevention RCTs. Accounting for such symptoms in RCTs is an ethical, scientific, and clinical imperative. Justifications for relapse prevention RCTs employing a discontinuation procedure require more scrutiny.

Exercise training impacts skeletal muscle gene expression related to the kynurenine pathway

Exercise positively impacts mood and symptoms of depression; however, the mechanisms underlying these effects are not fully understood. Recent evidence highlights a potential role for skeletal muscle-derived transcription factors to influence tryptophan metabolism, along the kynurenine pathway, which has important implications in depression. This has important consequences for older adults, whose age-related muscle deterioration may influence this pathway and may increase their risk for depression. Although exercise training has been shown to improve skeletal muscle mass in older adults, whether this also translates into improvements in transcription factors and metabolites related to the kynurenine pathway has yet to be examined. The aim of the present study was to examine the influence of a 12-wk exercise program on skeletal muscle gene expression of transcription factors, kynurenine aminotransferase (KAT) gene expression, and plasma concentrations of tryptophan metabolites (kynurenines) in healthy older men over 65 yr of age. Exercise training significantly increased skeletal muscle gene expression of transcription factors (peroxisome proliferator-activated receptor-γ coactivator 1α, peroxisome proliferator-activated receptor-α, and peroxisome proliferator-activated receptor-δ: 1.77, 1.99, 2.18-fold increases, respectively, P < 0.01] and KAT isoforms 1-4 (6.5, 2.1, 2.2, and 2.6-fold increases, respectively, P ≤ 0.01). Concentrations of plasma kynurenines were not altered. These results demonstrate that 12 wk of exercise training significantly altered skeletal muscle gene expression of transcription factors and gene expression related to the kynurenine pathway, but not circulating kynurenine metabolites in older men. These findings warrant future research to determine whether distinct exercise modalities or varying intensities could induce a shift in the kynurenine pathway in depressed older adults.

The Clinical Inadequacy of the Placebo Model and the Development of an Alternative Conceptual Framework

Placebo effects are often attributed to clinical interactions and contextual factors that affect expectations of the patient about the treatment and result in symptom changes. The prevailing conceptualization consists of an undifferentiated placebo response that needs to be minimized in controlled investigations and maximized in clinical practice. However, treatment outcome is the cumulative result of the interaction of several classes of variables with a selected treatment: living conditions (housing, nutrition, work environment, social support), patient characteristics (age, sex, genetics, general health conditions, personality, well-being), illness features and previous therapeutic experience, self-management, and treatment setting (physician's attitude and attention, illness behavior). Such variables may be therapeutic or countertherapeutic, and are unlikely to be simply additive. In certain patients their interactive combination may lead to clinical improvement, whereas in other cases it may produce no effect, and, in a third group, it may lead to worsening of the condition. Maximizing patients' expectations does not necessarily result in sustained effects and, in due course, may actually lead to worsening of the condition (violation of expectations). In this paper, we outline a multifactorial conceptual model that may have implications for the design of clinical trials as well as for clinical practice, with special reference to psychopharmacology and psychotherapy. The effects of drug treatment may be potentiated by specific nonpharmacological treatment strategies, and this synergism may disclose significant differences against placebo. Medical outcomes may be unsatisfactory not because technical interventions are missing, but because our conceptual models and thinking are inadequate.

Failure to Respond after Reinstatement of Antidepressant Medication: A Systematic Review

BACKGROUND

Following remission of an anxiety disorder or a depressive disorder, antidepressants are frequently discontinued and in the case of symptom occurrence reinstated. Reinstatement of antidepressants seems less effective in some patients, but an overview is lacking. This systematic review aimed to provide insight into the magnitude and risk factors of response failure after reinstatement of antidepressants in patients with anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), or posttraumatic stress disorder (PTSD).

METHOD

PubMed, Embase, and trial registers were systematically searched for studies in which patients: (1) had an anxiety disorder, a depressive disorder, OCD, or PTSD and (2) experienced failure to respond after reinstatement of a previously effective antidepressant.

RESULTS

Ten studies reported failure to respond following antidepressant reinstatement. The phenomenon was observed in 16.5% of patients with a depressive disorder, OCD, and social phobia and occurred in all common classes of antidepressants. The range of response failure was broad, varying between 3.8 and 42.9% across studies. No risk factors for failure to respond were investigated. The overall study quality was limited.

CONCLUSION

Research investigating response failure is scarce and the study quality limited. Response failure occurred in a substantial minority of patients. Contributors to the relevance of this phenomenon are the prevalence of the investigated disorders, the number of patients being treated with antidepressants, and the occurrence of response failure for all common classes of antidepressants. This systematic review highlights the need for studies systematically investigating this phenomenon and associated risk factors.

The Mortality and Myocardial Effects of Antidepressants Are Moderated by Preexisting Cardiovascular Disease: A Meta-Analysis

BACKGROUND

Antidepressants (ADs) are commonly prescribed medications, but their long-term health effects are debated. ADs disrupt multiple adaptive processes regulated by evolutionarily ancient biochemicals, potentially increasing mortality. However, many ADs also have anticlotting properties that can be efficacious in treating cardiovascular disease. We conducted a meta-analysis assessing the effects of ADs on all-cause mortality and cardiovascular events in general-population and cardiovascular-patient samples.

METHODS

Two reviewers independently assessed articles from PubMed, EMBASE, and Google Scholar for AD-related mortality controlling for depression and other comorbidities. From these articles, we extracted information about cardiovascular events, cardiovascular risk status, and AD class. We conducted mixed-effect meta-analyses testing sample type and AD class as moderators of all-cause mortality and new cardiovascular events.

RESULTS

Seventeen studies met our search criteria. Sample type consistently moderated health risks. In general-population samples, AD use increased the risks of mortality (HR = 1.33, 95% CI: 1.14-1.55) and new cardiovascular events (HR = 1.14, 95% CI: 1.08-1.21). In cardiovascular patients, AD use did not significantly affect risks. AD class also moderated mortality, but the serotonin reuptake inhibitors were not significantly different from tricyclic ADs (TCAs) (HR = 1.10, 95% CI: 0.93-1.31, p = 0.27). Only "other ADs" were differentiable from TCAs (HR = 1.35, 95% CI: 1.08-1.69). Mortality risk estimates increased when we analyzed the subset of studies controlling for premedication depression, suggesting the absence of confounding by indication.

CONCLUSIONS

The results support the hypothesis that ADs are harmful in the general population but less harmful in cardiovascular patients.

Does the death of a child influence parental use of psychotropic medication? A follow-up register study from Finland

Background

Several studies have found that the loss of a child is associated with psychiatric health problems, yet few studies examined whether child loss influences psychotropic medication use. This study examined short- and long-term use of psychotropic medication, both before and after the death of a child, and its potential effect modifiers.

Methodology/Principal findings

A random sample of 205,456 parents, including 902 bereaved parents, were selected from a Finnish total population registry. The analyses were based on linear regressions using generalised estimation equations (GEE) and adjusted for sociodemographic factors. Annual psychotropic use was defined as having purchased prescribed psychotropic medication between 1996 and2012. Bereaved parents were followed for four years prior to and up to four years after the death of their child. An increase in the use of antidepressants and anxiolytics was found in parents following their loss. The highest percentage of use was found around one year after bereavement, followed by a steady decrease although this remained higher than the level of use among non-bereaved four years after the death. Between 20–25% of bereaved mothers and 10–15% of bereaved fathers used antidepressants or anxiolytics one year after bereavement while the corresponding number in non-bereaved was 5–10%. An increase in psychotropic medication was also found several years before the disease-related loss of a child.

Conclusions/Significance

The use of psychotropic medication is markedly higher among parents after losing a child. Patterns of use leading up to and following the death of a child should be further examined in relation to clinical risk factors so as to identify at risk populations.

Medical subject headings

Bereavement, child death, psychotropic medication, death, child, register, Finland

Follow-up of monotherapy remitters in the PReDICT study: Maintenance treatment outcomes and clinical predictors of recurrence

OBJECTIVE

This study followed remitted patients from a randomized controlled trial of adults with major depressive disorder (MDD). The aims were to describe rates of recurrence and to evaluate 3 clinical predictor domains.

METHOD

Ninety-four treatment-naïve patients (50% female; Mage = 38.1 years; 48.9% White; 30.9% Hispanic) with MDD who had remitted to 12-week monotherapy (escitalopram, duloxetine, or cognitive behavior therapy [CBT]) participated in a 21-month maintenance phase (i.e., continued medication or 3 possible CBT booster sessions per year). Recurrence was assessed quarterly, and the clinical predictors were the following: 2 measures of residual depressive symptoms, 1 measure of lifetime depressive episodes, and 2 measures of baseline anxiety. Survival analysis models evaluated recurrence rates, and regression models evaluated the predictors.

RESULTS

Among all patients, 15.5% experienced a recurrence, and the survival distributions did not statistically differ among treatments. Residual depressive symptoms on the Hamilton Depression Rating Scale at the end of monotherapy were associated with increased risk for recurrence (hazard ratio = 1.31, 95% confidence interval [CI: 1.02, 1.67], Wald χ2 = 4.41, p = .036), and not having a comorbid anxiety disorder diagnosis at study baseline reduced the risk of recurrence (hazard ratio = .31, 95% CI [.10, .94], Wald χ2 = 4.28, p = .039).

CONCLUSIONS

The study supported the benefits of maintenance treatment for treatment-naïve patients who remitted to initial monotherapy; nevertheless, remitted patients with a comorbid anxiety disorder diagnosis at the beginning of treatment or residual depressive symptoms after initial treatment were at risk for poorer long-term outcomes. (PsycINFO Database Record

Well-being therapy in depression: New insights into the role of psychological well-being in the clinical process

A specific psychotherapeutic strategy for increasing psychological well-being and resilience, well-being therapy (WBT), has been developed and validated in a number of randomized controlled trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one's self, a sense of continued growth and development, the belief that life is purposeful and meaningful, the possession of quality relations with others, the capacity to manage effectively one's life, and a sense of self-determination. The evidence supporting the use of WBT and its specific contribution when it is combined with other psychotherapeutic techniques is still limited. However, the insights gained by the use of WBT may unravel innovative approaches to assessment and treatment of mood and anxiety disorders, to be confirmed by controlled studies, with particular reference to decreasing vulnerability to relapse and modulating psychological well-being and mood. An important characteristic of WBT is self-observation of psychological well-being associated with specific homework. Such perspective is different from interventions that are labeled as positive but are actually distress oriented. Another important feature of WBT is the assumption that imbalances in well-being and distress may vary from one illness to another and from patient to patient. Customary clinical taxonomy and evaluation do not include psychological well-being, which may demarcate major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same diagnosis.

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

Newer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.

Deep transcranial magnetic stimulation (dTMS) - beyond depression

INTRODUCTION

Deep transcranial magnetic stimulation (dTMS) utilizes different H-coils to study and treat a variety of psychiatric and neurological conditions with identifiable brain targets. The availability of this technology is dramatically changing the practice of psychiatry and neurology as it provides a safe and effective way to treat even drug-resistant patients. However, up until now, no effort was made to summarize the different types of H-coils that are available, and the conditions for which they were tested. Areas covered: Here we assembled all peer reviewed publication that used one of the H-coils, together with illustrations of the effective field they generate within the brain. Currently, the technology has FDA clearance for depression and European clearance for additional disorders, and multi-center trials are exploring its safety and effectiveness for OCD, PTSD, bipolar depression and nicotine addiction. Expert commentary: Taken together with positive results in smaller scale experiments, dTMS coils represent a non-invasive way to manipulate pathological activity in different brain structures and circuits. Advances in stimulation and imaging methods can now lead to efficacious and logical treatments. This should reduce the stigma associated with mental disorders, and improve access to psychiatric treatment.

The neuroscience and context of adolescent depression

Adolescent depression is a growing public health concern with an increased risk of negative health outcomes, including suicide. The use of antidepressants and psychotherapy has not halted its increasing prevalence, and there is a critical need for effective prevention and treatment. We reviewed the neuroscience of adolescent depression, with a focus on the neurocircuitry of sustained threat and summarised contextual factors that have an impact on brain development and the pathophysiology of depression. We also reviewed novel treatment models.

CONCLUSION

Attention to the relevant neurocircuitry and contextual factors implicated in adolescent depression is necessary to advance prevention and treatment development.