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Baune BT, Falkai P. Changes in antidepressant therapy should be considered early in patients with inadequate response to a first-line agent. Aust N Z J Psychiatry 2021; 55:1033-1038. [PMID: 33111538 DOI: 10.1177/0004867420968912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Deciding when and how to change treatment in patients with major depressive disorder who have inadequate response to initial antidepressant therapy is an important everyday clinical question. Here, we ask whether an early change of approach is superior to a delayed change. We consider the recommendations provided by recent guidelines, examine the evidence behind this guidance and suggest a decision tree to clarify treatment options and timing. Both the early and late-change strategies may have their place in clinical practice. However, we take the view that an earlier than currently usual change in antidepressant treatment should be considered more frequently in cases of non-response. Specific studies are needed to identify and to better understand predictors of early and late response.
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Affiliation(s)
- Bernhard T Baune
- Department of Psychiatry and Psychotherapy, University of Münster, Münster, Germany.,Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia.,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität München, Munich, Germany
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2
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Functional connectivity of the hippocampus in predicting early antidepressant efficacy in patients with major depressive disorder. J Affect Disord 2021; 291:315-321. [PMID: 34077821 DOI: 10.1016/j.jad.2021.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 02/08/2023]
Abstract
BAKGROUD The hippocampus is involved in the pathophysiology of major depressive disorder (MDD), and its structure and function have been reported to be related to the antidepressant response. This study aimed to identify relationships between hippocampal functional connectivity (FC) and early improvement in patients with MDD and to further explore the ability of hippocampal FC to predict early efficacy. METHODS Thirty-six patients with nonpsychotic MDD were recruited and underwent resting-state functional magnetic resonance imaging scans at baseline. After two weeks of treatment with escitalopram, patients were divided into subgroups with early improved depression (EID, n= 19) and nonimproved depression (NID, n=17) . A voxelwise FC analysis was performed with the bilateral hippocampus as seeds, two-sample t-tests were used to compare hippocampal FC between groups. Receiver operating characteristic (ROC) curves were constructed to determine the best FC measures and optimal threshold for differentiating EID from END. RESULTS The EID group showed significantly higher FC between the left hippocampus and left inferior frontal gyrus and precuneus than the END group. And the left hippocampal FC of these two regions were positively correlated with the reduction ratio of the depressive symptom scores. The ROC curve analysis revealed that summed FC scores for these two regions exhibited the highest area under the curve, with a sensitivity of 0.947 and specificity of 0.882 at a summed score of 0.14. LIMITATIONS The sample used in this study was relatively small. CONCLUSIONS These findings demonstrated that FC of the left hippocampus can predict early efficacy of antidepressant.
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Xiao L, Zhu X, Gillespie A, Feng Y, Zhou J, Chen X, Gao Y, Wang X, Ma X, Gao C, Xie Y, Pan X, Bai Y, Xu X, Wang G, Chen R. Effectiveness of mirtazapine as add-on to paroxetine v. paroxetine or mirtazapine monotherapy in patients with major depressive disorder with early non-response to paroxetine: a two-phase, multicentre, randomized, double-blind clinical trial. Psychol Med 2021; 51:1166-1174. [PMID: 31931894 DOI: 10.1017/s0033291719004069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study aimed to examine the efficacy of combining paroxetine and mirtazapine v. switching to mirtazapine, for patients with major depressive disorder (MDD) who have had an insufficient response to SSRI monotherapy (paroxetine) after the first 2 weeks of treatment. METHODS This double-blind, randomized, placebo-controlled, three-arm study recruited participants from five hospitals in China. Eligible participants were aged 18-60 years with MDD of at least moderate severity. Participants received paroxetine during a 2-week open-label phase and patients who had not achieved early improvement were randomized to paroxetine, mirtazapine or paroxetine combined with mirtazapine for 6 weeks. The primary outcome was improvement on the Hamilton Rating Scale for Depression 17-item (HAMD-17) scores 6 weeks after randomization. RESULTS A total of 204 patients who showed early non-response to paroxetine monotherapy were randomly assigned to receive either mirtazapine and placebo (n = 68), paroxetine and placebo (n = 68) or mirtazapine and paroxetine (n = 68), with 164 patients completing the outcome assessment. At week 8, the least squares (LS) mean change of HAMD-17 scores did not significantly differ among the three groups, (12.98 points) in the mirtazapine group, (12.50 points) in the paroxetine group and (13.27 points) in the mirtazapine plus paroxetine combination group. Participants in the paroxetine monotherapy group were least likely to experience adverse effects. CONCLUSIONS After 8 weeks follow-up, paroxetine monotherapy, mirtazapine monotherapy and paroxetine/mirtazapine combination therapy were equally effective in non-improvers at 2 weeks. The results of this trial do not support a recommendation to routinely offer additional treatment or a switch in treatment strategies for MDD patients who do not show early improvement after 2 weeks of antidepressant treatment.
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Affiliation(s)
- Le Xiao
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Xuequan Zhu
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Amy Gillespie
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Yuan Feng
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jingjing Zhou
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Xu Chen
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Yuanyuan Gao
- Department of Psychiatry, The First Hospital of Hebei Medical University, Hebei, China
| | - Xueyi Wang
- Department of Psychiatry, The First Hospital of Hebei Medical University, Hebei, China
| | - Xiancang Ma
- Department of Psychiatry, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, China
| | - Chengge Gao
- Department of Psychiatry, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, China
| | - Yunshi Xie
- Department of Neurology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Xiaoping Pan
- Department of Neurology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Yan Bai
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiufeng Xu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Runsen Chen
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Department of Psychiatry, University of Oxford, Oxford, UK
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4
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Jones BDM, Husain MI, Mulsant BH. The use of sequential pharmacotherapy for the treatment of acute major depression: a scoping review. Expert Opin Pharmacother 2021; 22:1005-1014. [PMID: 33612048 DOI: 10.1080/14656566.2021.1878144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Major Depressive Disorder (MDD) is a chronic, relapsing, and remitting disorder affecting over 250 million persons each year worldwide. More than 50% of the patients do not respond to their initial antidepressant treatment and may benefit from sequential pharmacotherapy for the acute treatment of their MDD. Although guidelines outline options for next-step treatments, there is a paucity of evidence to select specific second- or third-step treatments. AREAS COVERED This scoping review synthesizes and discusses available evidence for sequential pharmacotherapy for MDD. MEDLINE was searched from inception to 7 July 2020; 4490 studies were identified. We selected meta-analyses and reports on clinical trials that were judged to inform the sequential selection of pharmacotherapy for MDD. EXPERT OPINION Most relevant published trials are focused on, and support, the use of augmentation pharmacotherapy. There is also some support for other strategies such as combining or switching antidepressants. In the future, more studies need to directly compare these sequential options. To provide more personalized treatment within the framework of precision psychiatry, these studies should include an assessment of moderators and mediators ('mechanism') of antidepressant response.
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Affiliation(s)
- Brett D M Jones
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - M Ishrat Husain
- Department of Psychiatry, University of Toronto, Toronto, Canada.,General Adult Psychiatry and Health Systems Division, Centre for Addiction and Mental Health, Toronto, Canada
| | - Benoit H Mulsant
- Department of Psychiatry, University of Toronto, Toronto, Canada.,Adult Neurodevelopmental and Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Canada
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Malhi GS, Bell E, Bassett D, Boyce P, Bryant R, Hazell P, Hopwood M, Lyndon B, Mulder R, Porter R, Singh AB, Murray G. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2021; 55:7-117. [PMID: 33353391 DOI: 10.1177/0004867420979353] [Citation(s) in RCA: 246] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility. METHODS Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders. RESULTS The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg2020) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care. CONCLUSION The MDcpg2020 builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. MOOD DISORDERS COMMITTEE Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.
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Affiliation(s)
- Gin S Malhi
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | | | - Philip Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, Australia.,Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Philip Hazell
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, VIC, Australia
| | - Bill Lyndon
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Ajeet B Singh
- The Geelong Clinic Healthscope, IMPACT - Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Greg Murray
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, VIC, Australia
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Inoue T, Fujimoto S, Marumoto T, Kitagawa T, Ishida K, Nakajima T, Moriguchi Y, Fujikawa K, Watanabe K. Early Improvement with Vortioxetine Predicts Response and Remission: A Post Hoc Analysis of Data from a Clinical Trial Conducted in Japan. Neuropsychiatr Dis Treat 2021; 17:3735-3741. [PMID: 34955641 PMCID: PMC8694398 DOI: 10.2147/ndt.s340309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/03/2021] [Indexed: 01/18/2023] Open
Abstract
AIM Several weeks of treatment with an antidepressive agent may be required before efficacy is demonstrated in patients with major depressive disorder. This study investigated the predictive value of early partial improvement with vortioxetine for treatment response and remission. METHODS This was a post hoc analysis of an 8-week, randomized, double-blind, placebo-controlled, Phase 3 study of vortioxetine (10 mg or 20 mg) in Japanese patients aged 20-75 years with recurrent major depressive disorder and a Montgomery-Åsberg Depression Rating Scale (MADRS) score of at least 26. The key outcomes were the predictive value of early partial improvement (reduction in MADRS total score of ≥20% from baseline to week 2) with vortioxetine for MADRS response (≥50% decrease in score from baseline) and remission (decrease in score to ≤10) at week 8. RESULTS Relevant data were available for 478 patients; 62/158 patients receiving placebo, 71/162 receiving vortioxetine 10 mg, and 66/158 receiving vortioxetine 20 mg were early improvers. Early improvers receiving vortioxetine (10 mg or 20 mg) were more likely than non-early improvers to achieve a week 8 response (71.2-73.2% vs 29.7-38.0%) or remission (50.7-51.5% vs 17.4-18.7%). Positive predictive values for response and remission with vortioxetine were ~70% and ~50%, respectively; negative predictive values were ~70% and ~80%, respectively. CONCLUSION Improvement with vortioxetine may be predicted by early partial improvement in MADRS score. Some patients may benefit from longer-term treatment even without early improvement, another finding that may aid clinical decision-making. ClinicalTrials.gov registration for primary study: NCT02389816.
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Affiliation(s)
- Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Shinji Fujimoto
- Japan Medical Office, Takeda Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Tatsuro Marumoto
- Japan Medical Office, Takeda Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Tadayuki Kitagawa
- Takeda Development Center - Japan, Takeda Pharmaceutical Co., Ltd, Osaka, Japan
| | - Kazuyuki Ishida
- Takeda Development Center - Japan, Takeda Pharmaceutical Co., Ltd, Osaka, Japan
| | - Tadashi Nakajima
- Japan Medical Office, Takeda Pharmaceutical Co., Ltd, Tokyo, Japan
| | | | - Keita Fujikawa
- Japan Medical Office, Takeda Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
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7
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Köhler-Forsberg K, Jorgensen A, Dam VH, Stenbæk DS, Fisher PM, Ip CT, Ganz M, Poulsen HE, Giraldi A, Ozenne B, Jørgensen MB, Knudsen GM, Frokjaer VG. Predicting Treatment Outcome in Major Depressive Disorder Using Serotonin 4 Receptor PET Brain Imaging, Functional MRI, Cognitive-, EEG-Based, and Peripheral Biomarkers: A NeuroPharm Open Label Clinical Trial Protocol. Front Psychiatry 2020; 11:641. [PMID: 32792991 PMCID: PMC7391965 DOI: 10.3389/fpsyt.2020.00641] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/19/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Between 30 and 50% of patients with major depressive disorder (MDD) do not respond sufficiently to antidepressant regimens. The conventional pharmacological treatments predominantly target serotonergic brain signaling but better tools to predict treatment response and identify relevant subgroups of MDD are needed to support individualized and mechanistically targeted treatment strategies. The aim of this study is to investigate antidepressant-free patients with MDD using neuroimaging, electrophysiological, molecular, cognitive, and clinical examinations and evaluate their ability to predict clinical response to SSRI treatment as individual or combined predictors. METHODS We will include 100 untreated patients with moderate to severe depression (>17 on the Hamilton Depression Rating Scale 17) in a non-randomized open clinical trial. We will collect data from serotonin 4 receptor positron emission tomography (PET) brain scans, functional magnetic resonance imaging (fMRI), electroencephalogram (EEG), cognitive tests, psychometry, and peripheral biomarkers, before (at baseline), during, and after 12 weeks of standard antidepressant treatment. Patients will be treated with escitalopram, and in case of non-response at week 4 or intolerable side effects, offered to switch to a second line treatment with duloxetine. Our primary outcome (treatment response) is assessed using the Hamilton depression rating subscale 6-item scores at week 8, compared to baseline. In a subset of the patients (n = ~40), we will re-assess the neurobiological response (using PET, fMRI, and EEG) 8 weeks after initiated pharmacological antidepressant treatment, to map neurobiological signatures of treatment responses. Data from matched controls will either be collected or is already available from other cohorts. DISCUSSION The extensive investigational program with follow-up in this large cohort of participants provides a unique possibility to (a) uncover potential biomarkers for antidepressant treatment response, (b) apply the findings for future stratification of MDD, (c) advance the understanding of pathophysiological underpinnings of MDD, and (d) uncover how putative biomarkers change in response to 8 weeks of pharmacological antidepressant treatment. Our data can pave the way for a precision medicine approach for optimized treatment of MDD and also provides a resource for future research and data sharing. CLINICAL TRIAL REGISTRATION The study was registered at clinicaltrials.gov prior to initiation (NCT02869035; 08.16.2016, URL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02869035&cntry=&state=&city=&dist=).
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Affiliation(s)
- Kristin Köhler-Forsberg
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Anders Jorgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Vibeke H Dam
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Dea Siggaard Stenbæk
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Cheng-Teng Ip
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | - Melanie Ganz
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center Copenhagen, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Martin Balslev Jørgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibe Gedsoe Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
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8
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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.
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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
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9
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Köhler-Forsberg O, Larsen ER, Buttenschøn HN, Rietschel M, Hauser J, Souery D, Maier W, Farmer A, McGuffin P, Aitchison KJ, Uher R, Mors O. Effect of antidepressant switching between nortriptyline and escitalopram after a failed first antidepressant treatment among patients with major depressive disorder. Br J Psychiatry 2019; 215:494-501. [PMID: 30698114 PMCID: PMC6624130 DOI: 10.1192/bjp.2018.302] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND For patients with major depressive disorder (MDD) experiencing side-effects or non-response to their first antidepressant, little is known regarding the effect of switching between a tricyclic antidepressant (TCA) and a selective serotonin reuptake inhibitor (SSRI).AimsTo compare the switch between the TCA nortriptyline and the SSRI escitalopram. METHOD Among 811 adults with MDD treated with nortriptyline or escitalopram for up to 12 weeks, 108 individuals switched from nortriptyline to escitalopram or vice versa because of side-effects or non-response (trial registration: EudraCT No.2004-001723-38 (https://eudract.ema.europa.eu/) and ISRCTN No.03693000 (http://www.controlled-trials.com)). Patients were followed for up to 26 weeks after switching and response was measured with the Montgomery-Åsberg Depression Rating scale (MADRS). We performed adjusted mixed-effects linear regression models with full information maximum likelihood estimation reporting β-coefficients with 95% CIs. RESULTS Switching antidepressants resulted in a significant decrease in MADRS scores. This was present for switchers from escitalopram to nortriptyline (n = 36, β = -0.38, 95% CI -0.51 to -0.25, P<0.001) and from nortriptyline to escitalopram (n = 72, β = -0.34, 95% CI -0.41 to -0.26, P<0.001). Both switching options resulted in significant improvement among individuals who switched because of non-response or side-effects. The results were supported by analyses on other rating scales and symptom dimensions. CONCLUSIONS These results suggest that switching from a TCA to an SSRI or vice versa after non-response or side-effects to the first antidepressant may be a viable approach to achieve response among patients with MDD.Declarations of interestK.J.A. holds an Alberta Centennial Addiction and Mental Health Research Chair, funded by the Government of Alberta. K.J.A. has been a member of various advisory boards, received consultancy fees and honoraria, and has received research grants from various companies including Johnson and Johnson Pharmaceuticals Research and Development and Bristol-Myers Squibb Pharmaceuticals Limited. D.S. has served on advisory boards for, and received unrestricted grants from, Lundbeck and AstraZeneca. A.F. and P.M. have received honoraria for participating in expert panels for Lundbeck and GlaxoSmithKline.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital – Psychiatry, Denmark,Department of Clinical Medicine, Aarhus University, Denmark,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark,Corresponding author: Ole Köhler-Forsberg; Psychosis Research Unit; Aarhus University Hospital, Risskov; Skovagervej 2; DK-8240 Risskov; Phone: +45 2342 0661; ; Fax: +45 7847 1609
| | - Erik Roj Larsen
- Department of Psychiatry, Psychiatry in the Region of Southern Denmark; Institute of Clinical Research, Research Unit of Psychiatry, University of Southern Denmark
| | - Henriette N. Buttenschøn
- iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark,Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Denmark
| | - Marcella Rietschel
- Central Institute of Mental Health, Department of Genetic Epidemiology in Psychiatry, Medical Faculty Mannheim/Heidelberg University, Mannheim Germany
| | - Joanna Hauser
- Laboratory of Psychiatric Genetics, Department of Psychiatry, Poznan University of Medical Sciences, Poland
| | - Daniel Souery
- Laboratoire de Psychologie Médicale, Université Libre de Bruxelles; Psy Pluriel - Centre Européen de Psychologie Médicale, Belgium
| | | | - Anne Farmer
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
| | - Peter McGuffin
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
| | | | - Rudolf Uher
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK,Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Ole Mors
- Psychosis Research Unit, Aarhus University Hospital – Psychiatry, Denmark,Department of Clinical Medicine, Aarhus University, Denmark,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark
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10
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Measuring endogenous changes in serotonergic neurotransmission with [ 11C]Cimbi-36 positron emission tomography in humans. Transl Psychiatry 2019; 9:134. [PMID: 30975977 PMCID: PMC6459901 DOI: 10.1038/s41398-019-0468-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/24/2019] [Indexed: 12/28/2022] Open
Abstract
Developing positron emission tomography (PET) radioligands for the detection of endogenous serotonin release will enable the investigation of serotonergic deficits in many neuropsychiatric disorders. The present study investigates how acute challenges that aim to increase or decrease cerebral serotonin levels affect binding of the serotonin 2A receptor (5-HT2AR) agonist radioligand [11C]Cimbi-36. In a randomized, double-blind, placebo-controlled, three-arm design, 23 healthy volunteers were PET scanned twice with [11C]Cimbi-36: at baseline and following double-blind assignment to one of three interventions (1) infusion of the selective serotonin reuptake inhibitor (SSRI) citalopram preceded by oral dosing of the 5-HT1AR antagonist pindolol, (n = 8) (2) acute tryptophan depletion (ATD) (n = 7) and (3) placebo (n = 8). Two-sample t-tests revealed no significant group differences in percent change of neocortical [11C]Cimbi-36 binding from baseline to intervention between placebo and citalopram/pindolol (p = 0.4) or between placebo and ATD (p = 0.5). Notably, there was a significantly larger within-group variation in 5-HT2AR binding after intervention with citalopram/pindolol, as compared with placebo (p = 0.007). These findings suggest that neither ATD nor a combination of citalopram and pindolol elicit acute unidirectional changes in serotonin levels sufficient to be detected with [11C]Cimbi-36 PET in neocortex. We suggest that the large interindividual variation in 5-HT2AR binding after citalopram/pindolol reflects that after an acute SSRI intervention, individuals respond substantially different in terms of their brain serotonin levels. Our observation has a potential impact for the understanding of patient responses to SSRI.
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11
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Brendel M, Sauerbeck J, Greven S, Kotz S, Scheiwein F, Blautzik J, Delker A, Pogarell O, Ishii K, Bartenstein P, Rominger A. Serotonin Selective Reuptake Inhibitor Treatment Improves Cognition and Grey Matter Atrophy but not Amyloid Burden During Two-Year Follow-Up in Mild Cognitive Impairment and Alzheimer’s Disease Patients with Depressive Symptoms. J Alzheimers Dis 2018; 65:793-806. [DOI: 10.3233/jad-170387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | - Julia Sauerbeck
- Department of Nuclear Medicine, University of Munich, Germany
| | - Sonja Greven
- Department of Statistics, University of Munich, Germany
| | - Sebastian Kotz
- Department of Nuclear Medicine, University of Munich, Germany
| | | | | | - Andreas Delker
- Department of Nuclear Medicine, University of Munich, Germany
| | | | - Kazunari Ishii
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama City, Osaka, Japan
| | | | - Axel Rominger
- Department of Nuclear Medicine, University of Munich, Germany
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, Switzerland
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12
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Seo JS, Bahk WM, Wang HR, Woo YS, Park YM, Jeong JH, Kim W, Shim SH, Lee JG, Jon DI, Min KJ. Korean Medication Algorithm for Depressive Disorders 2017: Third Revision. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2018; 16:67-87. [PMID: 29397669 PMCID: PMC5810446 DOI: 10.9758/cpn.2018.16.1.67] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/01/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In 2002, the Korean Society for Affective Disorders developed the guidelines for the treatment of major depressive disorder (MDD), and revised it in 2006 and 2012. The third revision of these guidelines was undertaken to reflect advances in the field. METHODS Using a 44-item questionnaire, an expert consensus was obtained on pharmacological treatment strategies for MDD 1) without or 2) with psychotic features, 3) depression subtypes, 4) maintenance, 5) special populations, 6) the choice of an antidepressant (AD) regarding safety and adverse effects, and 7) non-pharmacological biological therapies. Recommended first, second, and third-line strategies were derived statistically. RESULTS AD monotherapy is recommended as the first-line strategy for non-psychotic depression in adults, children/adolescents, elderly adults, patient with persistent depressive disorder, and pregnant women or patients with postpartum depression or premenstrual dysphoric disorder. The combination of AD and atypical antipsychotics (AAP) was recommended for psychotic depression in adult, child/adolescent, postpartum depression, and mixed features or anxious distress. Most experts recommended stopping the ongoing initial AD and AAP after a certain period in patients with one or two depressive episodes. As an MDD treatment modality, 92% of experts are considering electroconvulsive therapy and 46.8% are applying it clinically, while 86% of experts are considering repetitive transcranial magnetic stimulation but only 31.6% are applying it clinically. CONCLUSION The pharmacological treatment strategy in 2017 is similar to that of Korean Medication Algorithm for Depressive Disorder 2012. The preference of AAPs was more increased.
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Affiliation(s)
- Jeong Seok Seo
- Department of Psychiatry, Konkuk University School of Medicine, Cheongju,
Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Hee Ryung Wang
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Young-Min Park
- Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang,
Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Won Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University College of Medicine, Seoul,
Korea
- Korea/Stress Research Institute, Inje University, Seoul,
Korea
| | - Se-Hoon Shim
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Jung Goo Lee
- Department of Psychiatry, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan,
Korea
- Paik Institute for Clinical Research, Department of Health Science and Technology, Graduate School of Inje University, Busan,
Korea
| | - Duk-In Jon
- Department of Psychiatry, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang,
Korea
| | - Kyung Joon Min
- Department of Psychiatry, Chung-Ang University College of Medicine, Seoul,
Korea
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13
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Olgiati P, Serretti A, Souery D, Dold M, Kasper S, Montgomery S, Zohar J, Mendlewicz J. Early improvement and response to antidepressant medications in adults with major depressive disorder. Meta-analysis and study of a sample with treatment-resistant depression. J Affect Disord 2018; 227:777-786. [PMID: 29254066 DOI: 10.1016/j.jad.2017.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/31/2017] [Accepted: 11/02/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Initial improvement in the first weeks of antidepressant (AD) treatment is a useful early predictor of complete AD response. We performed a meta-analysis of AD studies to investigate whether a partial decrease in depressive symptoms by week 4 was associated with response and remission by weeks 6-14 in major depressive disorder (MDD). Finally, we focused on treatment-resistant depression (TRD: lack of response to prior AD) to test the impact of early improvement on a second AD treatment outcome and to compare different switching strategies. METHODS Meta-analysis was conducted on AD naturalistic studies published between 01.01.2000 and 06.30.2017. TRD was an exclusion criterion. TRD was analyzed in 407 MDD patients treated with venlafaxine for 6 weeks. The MADRS was used to define very early improvement (VEI: > 20% decrease at week 2), early improvement (EI: > 30% decrease at week 4) and remission (week 6 MADRS < 10). A theoretical model was used to simulate AD switch in TRD patients who failed to achieve remission (Algorithm A), VEI (Algorithm B) or EI (Algorithm C). RESULTS Our meta-analysis (9 studies; N = 6185) showed significant associations between early improvement, response (OR: 3.28 95% C.I: 2.06-5.20) and remission (OR: 2.10 95% C.I: 1.53-2.87). 24.6% of TRD sample remitted. VEI was a poor outcome predictor: sensitivity = 0.52 (0.40-0.63); specificity = 0.82 (0.76-0.86); AUC = 0.67 (0.62-0.71). EI had a moderate predictive power: sensitivity = 0.87 (0.77-0.93); specificity = 0.71 (0.66-0.77); AUC = 0.76 (0.71-0.80). The best treatment scenario was Algorithm C (switch after 4 weeks) in which remission rate was marginally increased (35.1% vs 33.7% of Algorithm A). Algorithm B (switch after 2 weeks) led to a 4.3% decrease in remission compared to Algorithm A. LIMITATIONS Inclusion of a naturalistic sample without a control arm; simulation of treatments. CONCLUSION Although literature data suggest a correlation between an initial improvement of depressive symptoms and later response and remission during AD treatment, our analysis shows that such an early improvement is not a reliable outcome predictor in TRD. The nature of TRD is complex and different biological mechanisms and treatments might be necessary for TRD patients.
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Affiliation(s)
- Paolo Olgiati
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123 Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123 Bologna, Italy.
| | - Daniel Souery
- Laboratoire de Psychologie Médicale, Université Libre de Bruxelles, and Centre Européen de Psychologie Médicale-PsyPluriel, Brussels, Belgium
| | - Markus Dold
- Medical University of Vienna, Department of Psychiatry and Psychotherapy, Vienna, Austria
| | - Siegfried Kasper
- Medical University of Vienna, Department of Psychiatry and Psychotherapy, Vienna, Austria
| | | | - Joseph Zohar
- Chaim Sheba Medical Center, Chaim Sheba Medical Center, Tel-Hashomer, Israel
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14
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Nørgaard M, Ganz M, Svarer C, Fisher PM, Churchill NW, Beliveau V, Grady C, Strother SC, Knudsen GM. Brain Networks Implicated in Seasonal Affective Disorder: A Neuroimaging PET Study of the Serotonin Transporter. Front Neurosci 2017; 11:614. [PMID: 29163018 PMCID: PMC5682039 DOI: 10.3389/fnins.2017.00614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/20/2017] [Indexed: 11/13/2022] Open
Abstract
Background: Seasonal Affective Disorder (SAD) is a subtype of Major Depressive Disorder characterized by seasonally occurring depression that often presents with atypical vegetative symptoms such as hypersomnia and carbohydrate craving. It has recently been shown that unlike healthy people, patients with SAD fail to globally downregulate their cerebral serotonin transporter (5-HTT) in winter, and that this effect seemed to be particularly pronounced in female S-carriers of the 5-HTTLPR genotype. The purpose of this study was to identify a 5-HTT brain network that accounts for the adaption to the environmental stressor of winter in females with the short 5-HTTLPR genotype, a specific subgroup previously reported to be at increased risk for developing SAD. Methods: Nineteen females, either S' carriers (LG- and S-carriers) without SAD (N = 13, mean age 23.6 ± 3.2 year, range 19-28) or S' carriers with SAD (N = 6, mean age 23.7 ± 2.4, range 21-26) were PET-scanned with [11C]DASB during both summer and winter seasons (asymptomatic and symptomatic phase, 38 scans in total) in randomized order, defined as a 12-week interval centered on summer or winter solstice. We used a multivariate Partial Least Squares (PLS) approach with NPAIRS split-half cross-validation, to identify and map a whole-brain pattern of 5-HTT levels that distinguished the brains of females without SAD from females suffering from SAD. Results: We identified a pattern of 5-HTT levels, distinguishing females with SAD from those without SAD; it included the right superior frontal gyrus, brainstem, globus pallidus (bilaterally) and the left hippocampus. Across seasons, female S' carriers without SAD showed nominally higher 5-HTT levels in these regions compared to female S' carriers with SAD, but the group difference was only significant in the winter. Female S' carriers with SAD, in turn, displayed robustly increased 5-HTT levels in the ventral striatum (bilaterally), right orbitofrontal cortex, middle frontal gyrus (bilaterally), extending to the left supramarginal gyrus, left precentral gyrus and left postcentral gyrus during winter compared to female S' carriers without SAD. Limitations: The study is preliminary and limited by small sample size in the SAD group (N = 6). Conclusions: These findings provide novel exploratory evidence for a wintertime state-dependent difference in 5-HTT levels that may leave SAD females with the short 5-HTTLPR genotype more vulnerable to persistent stressors like winter. The affected brain regions comprise a distributed set of areas responsive to emotion, voluntary, and planned movement, executive function, and memory. The preliminary findings provide additional insight into the neurobiological components through which the anatomical distribution of serotonergic discrepancies between individuals genetically predisposed to SAD, but with different phenotypic presentations during the environmental stressor of winter, may constitute a potential biomarker for resilience against developing SAD.
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Affiliation(s)
- Martin Nørgaard
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melanie Ganz
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Claus Svarer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Patrick M. Fisher
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Vincent Beliveau
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cheryl Grady
- Rotman Research Institute, Baycrest and Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Stephen C. Strother
- Rotman Research Institute, Baycrest and Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Gitte M. Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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15
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Wagner S, Engel A, Engelmann J, Herzog D, Dreimüller N, Müller MB, Tadić A, Lieb K. Early improvement as a resilience signal predicting later remission to antidepressant treatment in patients with Major Depressive Disorder: Systematic review and meta-analysis. J Psychiatr Res 2017; 94:96-106. [PMID: 28697423 DOI: 10.1016/j.jpsychires.2017.07.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 07/02/2017] [Accepted: 07/02/2017] [Indexed: 10/19/2022]
Abstract
Early improvement of depressive symptoms during the first two weeks of antidepressant treatment has been discussed to be a resilience signal predicting a later positive treatment outcome in patients with Major Depressive Disorder (MDD). However, the predictive value of early improvement varies between studies, and the use of different antidepressants may explain heterogeneous results. The objective of this review was to assess the predictive value of early improvement on later response and remission and to identify antidepressants with the highest chance of early improvement. We included 17 randomized controlled trials investigating early improvement in 14,779 adult patients with MDD comparing monotherapy with an antidepressant against placebo or another antidepressant drug. 62% (range: 35-85%) of patients treated with an antidepressant and 47% (range: 21-69%) with placebo were early improver, defined as a >20%/25% symptom reduction after two weeks of treatment. Early improvement predicted response and remission after 5-12 weeks of treatment with high sensitivity (85%; 95%-CI: 84.3 to 85.7) and low to moderate specificity (54%; 95%-CI: 53.1 to 54.9). Early improver had a 8.37 fold (6.97-10.05) higher likelihood to become responder and a 6.38 fold (5.07-8.02) higher likelihood to be remitter at endpoint than non-improver. The highest early improver rates were achieved in patients treated with mirtazapine or a tricyclic antidepressant. This finding of a high predictive value of early improvement on treatment outcome may be important for treatment decisions in the early course of antidepressant treatment. Further studies should test the efficacy of such early treatment decisions.
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Affiliation(s)
- Stefanie Wagner
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany.
| | - Alice Engel
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany
| | - Jan Engelmann
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany
| | - David Herzog
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany
| | - Nadine Dreimüller
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany
| | - Marianne B Müller
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany
| | - André Tadić
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany; Agaplesion Elisabethenstift, Department of Psychiatry, Psychosomatics and Psychotherapy, Darmstadt, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University, Mainz, Germany.
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16
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Tokuoka H, Nishihara M, Fujikoshi S, Yoshikawa A, Kuga A. Predicting treatment outcomes of major depressive disorder by early improvement in painful physical symptoms: a pooled analysis of double-blind, placebo-controlled trials of duloxetine. Neuropsychiatr Dis Treat 2017; 13:2457-2467. [PMID: 29026309 PMCID: PMC5626379 DOI: 10.2147/ndt.s143093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE We determined if early improvement in painful physical symptoms (PPS) can be a predictor of remission in the treatment of major depressive disorder (MDD). METHODS We included randomized, double-blind, parallel-group clinical trials of duloxetine (40-60 mg/day) versus placebo for the acute treatment of MDD with associated PPS. Only those studies using the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Brief Pain Inventory - Short Form (BPI-SF) were included. Three studies met all criteria and included male or female outpatients aged ≥18 years who met the diagnostic criteria for MDD, had a MADRS total score ≥20, and had at least moderate pain (BPI-SF average pain score ≥3). Positive predictive values (PPVs) and negative predictive values (NPVs) of early improvement in PPS for remission were analyzed. PPVs were the proportion of patients with remission (MADRS total score ≤10) at week 8 out of patients who experienced early improvement in BPI-SF average pain score (≥30% decrease from baseline at week 1, 2, or 4). NPVs were the proportion of patients without remission (MADRS total score >10) at week 8 out of patients who did not experience early improvement in PPS. RESULTS Data from 1,320 patients were analyzed (duloxetine N=641 and placebo N=679). The overall remission (MADRS total score ≤10 at week 8) rate for the duloxetine group was significantly higher than the placebo group (38.5% vs 21.8%; P<0.0001). For both treatment groups, PPVs of early improvement in BPI-SF (30% improvement from baseline) were higher than the overall remission rate for all weeks examined (weeks 1, 2, and 4); in general, NPVs of early improvement in BPI-SF for nonremission were higher than the overall nonremission rate. CONCLUSION Early improvement in PPS can be a useful clinical indicator of subsequent treatment outcome for MDD patients with associated PPS.
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Affiliation(s)
- Hirofumi Tokuoka
- Bio-Medicine, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe
| | - Makoto Nishihara
- Multidisciplinary Pain Center, Aichi Medical University, Nagakute, Aichi
| | | | - Aki Yoshikawa
- Scientific Communications, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
| | - Atsushi Kuga
- Bio-Medicine, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe
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17
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[Unsatisfactory response: definition and involvement]. Encephale 2016; 42:1S31-8. [PMID: 26879255 DOI: 10.1016/s0013-7006(16)30017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the treatment of unipolar depression, treatment response is a key issue in terms of evolution and prognosis. Within this concept, the inadequate response includes the worsening, the lack of response, partial response and poor tolerance. This lack of response may be related to intrinsic factors to the individual, but also to more extrinsic environmental factors. In this review, we explore this concept through its links with adherence and treatment duration. In this field, the concept of early response can be a powerful indicator of therapeutic response, which conditions the prescription of antidepressants beyond the strict framework of the sufficient period of 4 to 6 weeks. In addition to its impact on prognosis, the literature data show that the insufficient response is a significant burden in terms of medical and economic cost, and somatic comorbidity; and justifies a systematic identification of this dimension. Therefore self-reports (QIDS; BDI) will be preferred to the clinician-rated depression symptom rating scales (MADRS, HAMD) that require a specific training. Identifying predictors of non-response would be an attractive target for prescribers but the results to date are not operative.
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18
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Uchida T, Kishimoto T, Koreki A, Nakao S, Owada A, Koizumi T, Saito A, Sato M, Sawada S, Matsuzaki R, Petrides G, Mimura M. Predictors of readmission after successful electroconvulsive therapy for depression: a chart review study. Int J Psychiatry Clin Pract 2016; 20:260-4. [PMID: 27541857 DOI: 10.1080/13651501.2016.1209220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The study aimed to identify the predictors for readmission after a successful electroconvulsive therapy (ECT) course. METHODS Medical charts of patients who received ECT for major depressive episodes were reviewed. Patients' demographic characteristics and treatment parameters, such as ECT charge, seizure duration, the number of ECT sessions and pharmacotherapy, were extracted. We compared differences between those who were readmitted after successful ECT within 6 and 12 months, versus those not readmitted. We also conducted a multivariate logistic regression analysis to identify the predictors for readmission. RESULTS Out of 51 patients who were discharged after ECT, 27 patients met the inclusion criteria and were included in the analysis. Eight patients were readmitted within 6 months after discharge, and four more patients were readmitted during the next 6-month follow up. Comparing patients who were and were not readmitted, we found no significant differences between groups, including ECT parameters such as the number of ECT sessions, average charge and final charge. No predictors for readmission were found through multivariate analysis. CONCLUSIONS Although patients who require higher ECT charge and more sessions seem to be prone to readmission, our dataset suggested that none of these types of ECT parameters were risk factors for readmission.
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Affiliation(s)
- Takahito Uchida
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan ;,b Department of Neuropsychiatry , Kawasaki Municipal Hospital , Kanagawa , Japan
| | - Taishiro Kishimoto
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan ;,c The Zucker Hillside Hospital , Glen Oaks , NY , USA
| | - Akihiro Koreki
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Shigetsugu Nakao
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Ai Owada
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Teruki Koizumi
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Atsuyuki Saito
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Minako Sato
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Shinya Sawada
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | - Ryuta Matsuzaki
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
| | | | - Masaru Mimura
- a Department of Neuropsychiatry , Keio University School of Medicine , Tokyo , Japan
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Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P, Hasnain M, Jollant F, Levitt AJ, MacQueen GM, McInerney SJ, McIntosh D, Milev RV, Müller DJ, Parikh SV, Pearson NL, Ravindran AV, Uher R. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:540-60. [PMID: 27486148 PMCID: PMC4994790 DOI: 10.1177/0706743716659417] [Citation(s) in RCA: 688] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. METHODS Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Pharmacological Treatments" is the third of six sections of the 2016 guidelines. With little new information on older medications, treatment recommendations focus on second-generation antidepressants. RESULTS Evidence-informed responses are given for 21 questions under 4 broad categories: 1) principles of pharmacological management, including individualized assessment of patient and medication factors for antidepressant selection, regular and frequent monitoring, and assessing clinical and functional outcomes with measurement-based care; 2) comparative aspects of antidepressant medications based on efficacy, tolerability, and safety, including summaries of newly approved drugs since 2009; 3) practical approaches to pharmacological management, including drug-drug interactions and maintenance recommendations; and 4) managing inadequate response and treatment resistance, with a focus on switching antidepressants, applying adjunctive treatments, and new and emerging agents. CONCLUSIONS Evidence-based pharmacological treatments are available for first-line treatment of MDD and for management of inadequate response. However, given the limitations of the evidence base, pharmacological management of MDD still depends on tailoring treatments to the patient.
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Affiliation(s)
- Sidney H Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario *Co-first authors.
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia *Co-first authors
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | | - Venkat Bhat
- Department of Psychiatry, McGill University, Montréal, Quebec
| | - Pierre Blier
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario
| | - Mehrul Hasnain
- Department of Psychiatry, Memorial University, St. John's, Newfoundland
| | - Fabrice Jollant
- Department of Psychiatry, McGill University, Montréal, Quebec
| | - Anthony J Levitt
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | | | | - Diane McIntosh
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
| | - Roumen V Milev
- Department of Psychiatry, Queen's University, Kingston, Ontario
| | - Daniel J Müller
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Sagar V Parikh
- Department of Psychiatry, University of Toronto, Toronto, Ontario Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | | | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Rudolf Uher
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia
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20
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Lopez-Castroman J, Jaussent I, Gorwood P, Courtet P. SUICIDAL DEPRESSED PATIENTS RESPOND LESS WELL TO ANTIDEPRESSANTS IN THE SHORT TERM. Depress Anxiety 2016; 33:483-94. [PMID: 26882201 DOI: 10.1002/da.22473] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Suicidal thoughts and behaviors could be associated to a poor response to antidepressant treatment, but the exclusion of suicidal patients from randomized clinical trials restricts the available knowledge. In this study, we aimed at defining more precisely the response to antidepressants among suicidal patients and the threshold of suicidality that best predicts a poor response. METHOD We investigated the short-term response to a new antidepressant treatment of 4,041 depressed outpatients depending on their suicidal status (passive or active suicidal ideation (SI), history of suicide attempts [SAs]), either self-rated or clinician-rated. Depression outcomes, measured with the Hospital Anxiety and Depression Scale, and remission rates were compared depending on suicidal status at baseline using logistic regression models. RESULTS Using either a qualitative or a quantitative approach to measure SI, we found that suicidal patients were less likely to improve or attain remission, but not more likely to worsen, than nonsuicidal patients. In the multivariate analyses, SI (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.18-1.65) and a history of SA (OR = 1.39; 95% CI: 1.16-1.66) were the best predictors of nonremission, independently of the class of antidepressant treatment. CONCLUSION Antidepressant treatment seems to be less effective among those patients that need it most. Clinical trials including suicidal patients are needed to investigate specific treatment options.
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Affiliation(s)
- Jorge Lopez-Castroman
- Department of Psychiatry, CHRU Nimes, Nimes, France.,Inserm, U1061, Université Montpellier, Montpellier, France.,Fondamental Foundation, Créteil, France
| | | | - Philip Gorwood
- Department of Psychiatry, Sainte-Anne Hospital (CMME), Paris, France.,INSERM U894, (Center of Psychiatry and Neurosciences), Paris, France.,Department of Psychiatry, University Paris Descartes, Paris, France
| | - Philippe Courtet
- Inserm, U1061, Université Montpellier, Montpellier, France.,Fondamental Foundation, Créteil, France.,Department of Emergency Psychiatry and Post-Acute Care, CHRU Montpellier, Montpellier, France
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21
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Tadić A, Wachtlin D, Berger M, Braus DF, van Calker D, Dahmen N, Dreimüller N, Engel A, Gorbulev S, Helmreich I, Kaiser AK, Kronfeld K, Schlicht KF, Tüscher O, Wagner S, Hiemke C, Lieb K. Randomized controlled study of early medication change for non-improvers to antidepressant therapy in major depression--The EMC trial. Eur Neuropsychopharmacol 2016; 26:705-16. [PMID: 26899588 DOI: 10.1016/j.euroneuro.2016.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 01/26/2016] [Accepted: 02/01/2016] [Indexed: 12/28/2022]
Abstract
Patients with Major Depressive Disorder (MDD) and no improvement after two weeks of antidepressant pharmacotherapy have a high risk of treatment failure. The aim of the study was to determine whether an early medication change (EMC) strategy is superior to a guideline-based treatment in MDD patients without improvement after two weeks of antidepressant pharmacotherapy. Eight-hundred-and-eighty-nine patients with MDD were enrolled, 879 patients received the SSRI escitalopram. Of those, 192 patients had no improvement, defined as a reduction of < 20% on the Hamilton Depression Rating Scale (HAMD-17) after 14 days of treatment, and were randomly assigned to open treatment with the EMC strategy (n = 97; venlafaxine XR for study days 15-56; in case of sustained non-improvement on day 28, lithium augmentation for days 29-56) or TAU (n = 95; escitalopram continuation; non-responders on day 28 were switched to venlafaxine XR for four weeks, i.e. days 29-56). The primary outcome was remission (HAMD-17 ≤ 7) after 8 weeks of treatment as assessed by blinded raters. Remission rates were 24% for EMC and 16% for TAU, which was not significantly different (p = 0.2056). Sensitivity analyses for the primary and secondary effectiveness endpoints consistently showed favorable results for patients randomized to EMC. The results confirm data from post-hoc analyses of clinical trials showing that early non-improvement identifies patients who likely need alternate interventions. However, the herein used two-step switch/augmentation strategy for this risk group was not more effective than the control intervention. Alternate strategies and other design aspects are discussed in order to support researchers addressing the same research question.
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Affiliation(s)
- André Tadić
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany.
| | - Daniel Wachtlin
- Interdisciplinary Centre for Clinical Trials (IZKS), University Medical Center Mainz, Germany
| | - Mathias Berger
- Department of Psychiatry and Psychotherapy of the University of Freiburg, Germany
| | - Dieter F Braus
- Department of Psychiatry and Psychotherapy, HELIOS Dr.-Horst-Schmidt-Hospital, Wiesbaden, Germany
| | - Dietrich van Calker
- Department of Psychiatry and Psychotherapy of the University of Freiburg, Germany
| | - Norbert Dahmen
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany; Hospital for Psychiatry and Psychotherapy, Katzenelnbogen, Germany
| | - Nadine Dreimüller
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Alice Engel
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Stanislav Gorbulev
- Interdisciplinary Centre for Clinical Trials (IZKS), University Medical Center Mainz, Germany
| | - Isabella Helmreich
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Anne-Katrin Kaiser
- Interdisciplinary Centre for Clinical Trials (IZKS), University Medical Center Mainz, Germany
| | - Kai Kronfeld
- Interdisciplinary Centre for Clinical Trials (IZKS), University Medical Center Mainz, Germany
| | - Konrad F Schlicht
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Oliver Tüscher
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Stefanie Wagner
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Germany
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22
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Brignone M, Diamand F, Painchault C, Takyar S. Efficacy and tolerability of switching therapy to vortioxetine versus other antidepressants in patients with major depressive disorder. Curr Med Res Opin 2016; 32:351-66. [PMID: 26637048 DOI: 10.1185/03007995.2015.1128404] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the relative efficacy and tolerability of vortioxetine against different antidepressant monotherapies in patients with major depressive disorder (MDD) with inadequate response to selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) therapy. METHODS A systematic search was conducted for monotherapy studies in patients with MDD with inadequate response to first-line therapy. Treatments included SSRIs, SNRIs, and other antidepressants. Identified studies underwent a three-stage screening/data extraction process and critical appraisal. Adjusted indirect treatment comparisons (ITCs) on systematic literature review outputs were made using Bucher's method, comparing remission rates and withdrawal rates due to adverse events (AEs). RESULTS Of 27 studies meeting the inclusion criteria, a few studies were of high quality according to the National Institute of Health and Care Excellence checklist. Three studies contributed to an evidence network for quantitative assessment comparing vortioxetine with agomelatine, sertraline, venlafaxine XR, and bupropion SR. Vortioxetine had a statistically significantly higher remission rate than agomelatine (risk difference [RD]: -11.0% [95% CI: -19.4; -2.6]), and numerically higher remission rates than sertraline (RD: -14.4% [95% CI: -29.9; 1.1]), venlafaxine (RD: -7.20% [95% CI: -24.3; 9.9]), and bupropion (RD: -10.70% [95% CI: -27.8; 6.4]). Withdrawal rates due to AEs were statistically significantly lower for vortioxetine than sertraline (RD: 12.1% [95% CI: 3.1; 21.1]), venlafaxine XR (RD: 12.3% [95% CI: 0.8; 23.8]), and bupropion SR (RD: 18.3% [95% CI: 6.4; 30.1]). CONCLUSIONS The current systematic literature review found a few high quality switch studies assessing monotherapies in patients with MDD with inadequate response to SSRI/SNRIs. ITCs indicated that switching to vortioxetine leads to numerically higher remission rates compared with other antidepressants. Vortioxetine is a well tolerated treatment, showing statistically lower withdrawal rates due to AEs compared with other antidepressants. Vortioxetine is a relevant therapeutic alternative in patients experiencing inadequate response to prior SSRI or SNRI therapy.
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23
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Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, Hopwood M, Lyndon B, Mulder R, Murray G, Porter R, Singh AB. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2015; 49:1087-206. [PMID: 26643054 DOI: 10.1177/0004867415617657] [Citation(s) in RCA: 511] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility. METHODS Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders. RESULTS The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care. CONCLUSIONS The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. MOOD DISORDERS COMMITTEE Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh. INTERNATIONAL EXPERT ADVISORS Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham. AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.
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Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Kolling Institute, Sydney Medical School, University of Sydney, Sydney, NSW, Australia CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Darryl Bassett
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia School of Medicine, University of Notre Dame, Perth, WA, Australia
| | - Philip Boyce
- Discipline of Psychiatry, Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School and The Alfred, Melbourne, VIC, Australia
| | - Kristina Fritz
- CADE Clinic, Discipline of Psychiatry, Sydney Medical School - Northern, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Bill Lyndon
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia Mood Disorders Unit, Northside Clinic, Greenwich, NSW, Australia ECT Services Northside Group Hospitals, Greenwich, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago-Christchurch, Christchurch, New Zealand
| | - Greg Murray
- Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Richard Porter
- Department of Psychological Medicine, University of Otago-Christchurch, Christchurch, New Zealand
| | - Ajeet B Singh
- School of Medicine, Deakin University, Geelong, VIC, Australia
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24
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Shen Y, Yao J, Jiang X, Zhang L, Xu L, Feng R, Cai L, Liu J, Wang J, Chen W. Sub-hubs of baseline functional brain networks are related to early improvement following two-week pharmacological therapy for major depressive disorder. Hum Brain Mapp 2015; 36:2915-27. [PMID: 25930660 DOI: 10.1002/hbm.22817] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/31/2015] [Accepted: 04/13/2015] [Indexed: 11/10/2022] Open
Abstract
Accumulating evidence suggests that early improvement after two-week antidepressant treatment is predictive of later outcomes of patients with major depressive disorder (MDD); however, whether this early improvement is associated with baseline neural architecture remains largely unknown. Utilizing resting-state functional MRI data and graph-based network approaches, this study calculated voxel-wise degree centrality maps for 24 MDD patients at baseline and linked them with changes in the Hamilton Rating Scale for Depression (HAMD) scores after two weeks of medication. Six clusters exhibited significant correlations of their baseline degree centrality with treatment-induced HAMD changes for the patients, which were mainly categorized into the posterior default-mode network (i.e., the left precuneus, supramarginal gyrus, middle temporal gyrus, and right angular gyrus) and frontal regions. Receiver operating characteristic curve and logistic regression analyses convergently revealed excellent performance of these regions in discriminating the early improvement status for the patients, especially the angular gyrus (sensitivity and specificity of 100%). Moreover, the angular gyrus was identified as the optimal regressor as determined by stepwise regression. Interestingly, these regions possessed higher centrality than others in the brain (P < 10(-3)) although they were not the most highly connected hubs. Finally, we demonstrate a high reproducibility of our findings across several factors (e.g., threshold choice, anatomical distance, and temporal cutting) in our analyses. Together, these preliminary exploratory analyses demonstrate the potential of neuroimaging-based network analysis in predicting the early therapeutic improvement of MDD patients and have important implications in guiding earlier personalized therapeutic regimens for possible treatment-refractory depression.
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Affiliation(s)
- Yuedi Shen
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Jiashu Yao
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China
| | - Xueyan Jiang
- Center for Cognition and Brain Disorders, Hangzhou Normal University, Hangzhou, Zhejiang, China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, Zhejiang, China
| | - Lei Zhang
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China
| | - Luoyi Xu
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China
| | - Rui Feng
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China
| | - Liqiang Cai
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China
| | - Jing Liu
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China
| | - Jinhui Wang
- Center for Cognition and Brain Disorders, Hangzhou Normal University, Hangzhou, Zhejiang, China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, Zhejiang, China
| | - Wei Chen
- Department of Psychiatry, Sir Run Run Shaw Hospital, Zhejiang University School of Medical and the Collaborative Innovation Center for Brain Science, Hangzhou, Zhejiang, China.,Key Laboratory of Medical Neurobiology of Chinese Ministry of Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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25
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Effects of age on paroxetine efficacy in patients with major depressive disorder who do not exhibit an early response to treatment. Clin Neuropharmacol 2015; 38:6-10. [PMID: 25580920 DOI: 10.1097/wnf.0000000000000058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We investigated the effects of age on the association between early and eventual responses to paroxetine treatment in patients with major depressive disorder (MDD). METHODS Eighty-nine patients with MDD were administered paroxetine and completed the 6-week protocol. On the basis of our previous study, we defined early responders as those patients with the Montgomery-Asberg Depression Rating Scale (MADRS) improvements higher than 35% at 2 weeks and responders as those patients with MADRS improvements higher than 50% at 6 weeks. The participants were divided into 4 groups in accordance with their responses: early response responders, early response nonresponders, nonearly response responders (NER-Rs), and nonearly response nonresponders (NER-NRs). Demographic data and the MADRS scores between the early response responders and the early response nonresponders and between the NER-Rs and the NER-NRs were compared. We used a receiver operating characteristic (ROC) curve to analyze age to determine the cutoff points for distinguishing responders and nonresponders in early and nonearly responders. RESULTS There was a significant difference in age between the NER-Rs and the NER-NRs, with the NER-Rs being younger than the NER-NRs. The threshold for the response in the early responders was 42 years old. The area under the curve of the ROC curve of the early responders was 0.548. The threshold for the response of the nonearly responders was 55 years old. The area under the curve of the ROC curve of the early responders was 0.733. CONCLUSIONS The effects of age on the association between the responsiveness in the early phase of antidepressant treatment and the eventual response were identified in patients with MDD.
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Early switching strategies in antidepressant non-responders: current evidence and future research directions. CNS Drugs 2014; 28:601-9. [PMID: 24831418 DOI: 10.1007/s40263-014-0171-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Studies have found that up to two-thirds of patients with major depressive disorder (MDD) do not fully respond to the first antidepressant. While switching antidepressants is a common strategy for antidepressant non-responders, there is still a lack of consensus about the optimal timing of a switch. Many clinicians wait for 6-12 weeks before considering a switch. The objectives of this paper are to (1) review the evidence for positive and negative predictive value (NPV) of early improvement at 2-4 weeks to predict final antidepressant response; (2) review randomized controlled trials (RCTs) that examine early switching strategies; and (3) provide future research directions and clinical recommendations for timing of antidepressant switching. We conducted a literature search for English-language studies via PubMed and Google Scholar, from 1984 to May 2013, with the following terms: 'antidepressants', 'MDD', 'time course', 'trajectory', 'early response', 'onset', 'delayed response', 'early improvement', 'predictors', 'switch', 'combination therapy', and 'augmentation'. Replicated evidence indicates that lack of early improvement (e.g. <20% reduction in a depression scale score) at 2-4 weeks can be an accurate predictor to identify eventual non-responders. The NPVs suggest that only about one in five patients with lack of improvement at 4 weeks will have a response by 8 weeks. Three RCTs examined early switch strategies, but results are inconsistent and comparisons limited by methodological differences. Future studies should incorporate a standard consensus definition of early improvement, discern whether the effect of early switching is specific to certain types of antidepressants, and determine whether early switch is superior to other strategies such as augmentation or combination. Notwithstanding these limitations, there is reasonable evidence to recommend earlier assessment for improvement. If there is no indication of early improvement at 2-4 weeks after starting an antidepressant, and taking into account other patient and clinical factors, a change in management can be considered.
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Early improvement in depressive symptoms with desvenlafaxine 50 mg/d as a predictor of treatment success in patients with major depressive disorder. J Clin Psychopharmacol 2014; 34:57-65. [PMID: 24346751 DOI: 10.1097/jcp.0000000000000049] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This post hoc analysis assessed the predictive value of improvement in depressive scores at early time points for treatment outcomes at week 8 in patients with major depressive disorder treated with desvenlafaxine 50 mg/d or placebo. METHODS Pooled data from 6 double-blind, fixed-dose studies in adult patients with major depressive disorder. Patients were randomly assigned to desvenlafaxine or placebo. Primary end point was change in 17-item Hamilton Rating Scale for Depression (HAM-D17) scores from baseline to week 8 (or last observation carried forward). Optimal thresholds of improvement (percent change from baseline HAM-D17) at weeks 2 and 3 for predicting 4 levels of treatment success (≥ 45%, ≥ 50%, and ≥ 65% decrease from baseline HAM-D17, HAM-D17 ≤ 7) at week 8 (last observation carried forward) were determined using receiver operating characteristic analysis. Odds ratios of the predictability of improvement thresholds were computed from a logistic regression model adjusting for significant baseline predictors. RESULTS Desvenlafaxine 50 mg/d (n = 1207) had significantly greater rates of treatment success for each level of treatment success at 8 weeks compared with placebo (n = 1067). Optimal early improvement thresholds for weeks 2 (20%-30%) and 3 (28%-41%) were highly predictive of all 4 levels of treatment success after adjusting for significant baseline predictors (odds ratios, 0.951-0.960; all P < 0.0001). Negative predictive value of early improvement increased, and positive predictive value decreased, for increasingly stringent definitions of treatment success at week 8. CONCLUSIONS Clinical observations of patients' early response to desvenlafaxine 50 mg/d may have clinical value in predicting treatment success and guiding patient management.
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Tomita T, Yasui-Furukori N, Sato Y, Nakagami T, Tsuchimine S, Kaneda A, Kaneko S, Kaneko S. Sex differences in the prediction of the effectiveness of paroxetine for patients with major depressive disorder identified using a receiver operating characteristic curve analysis for early response. Neuropsychiatr Dis Treat 2014; 10:599-606. [PMID: 24748795 PMCID: PMC3986275 DOI: 10.2147/ndt.s57189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We investigated cutoff values for the early response of patients with major depressive disorder to paroxetine and their sex differences by using a receiver operating characteristic (ROC) curve analysis to predict the effectiveness of paroxetine. METHODS In total, 120 patients with major depressive disorder were enrolled and treated with 10-40 mg/day paroxetine for 6 weeks; 89 patients completed the protocol. A clinical evaluation using the Montgomery-Asberg Depression Rating Scale (MADRS) was performed at weeks 0, 1, 2, 4, and 6. RESULTS In male subjects, the cutoff values for MADRS improvement rating in week 1, week 2, and week 4 were 20.9%, 34.9%, and 33.3%, respectively. The sensitivities and the specificities were 83.3% and 80.0%, 83.3% and 80.0%, and 100% and 90%, respectively. The areas under the curve (AUC) were 0.908, 0.821, and 0.979, respectively. In female subjects, the cutoff values for the MADRS improvement rating in week 1, week 2, and week 4 were 21.4%, 35.7%, and 32.3%, respectively. The sensitivities and the specificities were 71.4% and 84.6%, 73.8% and 76.9%, and 90.5% and 76.9%, respectively. The AUCs were 0.781, 0.735, and 0.904, respectively. CONCLUSION Early improvement with paroxetine may predict the long-term response. The accuracy of the prediction for the response is higher in male subjects.
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Affiliation(s)
- Tetsu Tomita
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Norio Yasui-Furukori
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Yasushi Sato
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Taku Nakagami
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Shoko Tsuchimine
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Ayako Kaneda
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Sunao Kaneko
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Sunao Kaneko
- Department of Neuropsychiatry, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
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Malhi GS, Hitching R, Berk M, Boyce P, Porter R, Fritz K. Pharmacological management of unipolar depression. Acta Psychiatr Scand Suppl 2013:6-23. [PMID: 23586873 DOI: 10.1111/acps.12122] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To be used in conjunction with 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of pharmacological treatments in depression derived from a literature review. METHOD Using our previous Clinical Practice Guidelines [Malhi et al. Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand 2009;119(Suppl. 439):27-46] as a foundation, these clinician guidelines target key practical considerations when prescribing pharmacotherapy. A comprehensive review of the literature was conducted using electronic database searches (PubMed, MEDLINE), and the findings have been synthesized and integrated alongside clinical experience. RESULTS The pharmacotherapy of depression is an iterative process that often results in partial and non-response. Beyond the initiation of antidepressants, the options within widely used strategies, such as combining agents and switching between agents, are difficult to prescribe because of the paucity of pertinent research. However, there is some evidence for second-line strategies, and a non-prescriptive algorithm can be derived that is based broadly on principles rather than specific steps. CONCLUSION Depression is by its very nature a heterogeneous illness that is consequently difficult to treat. Invariably, situation-specific factors often play a significant role and must be considered, especially in the case of partial and non-response. Consulting with colleagues and trialling alternate treatment paradigms are essential strategies in the management of depression.
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Affiliation(s)
| | | | | | - P. Boyce
- Discipline of Psychiatry; Sydney Medical School; University of Sydney; Sydney; NSW; Australia
| | - R. Porter
- Department of Psychological Medicine; University of Otago; Christchurch; New Zealand
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Clinical features and drug induced side effects in early versus late antidepressant responders. J Psychiatr Res 2013; 47:1309-18. [PMID: 23800418 DOI: 10.1016/j.jpsychires.2013.05.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 05/19/2013] [Accepted: 05/21/2013] [Indexed: 01/10/2023]
Abstract
Early antidepressant response (2nd week) has been reported as the result of a true antidepressant effect and a predictor of subsequent stable response. With the purpose to study the clinical profile of early response/remission (2nd week) compared to late response/remission (4th-6th weeks), two independent major depressive disorder (MDD) samples (the Sequenced Treatment Alternatives to Relieve Depression or STAR*D n=1922 and an Italian sample n=171) were investigated. Patients were treated with citalopram in the STAR*D while in a naturalistic setting in the Italian sample. Depressive symptomatology was assessed by the Hamilton Depressive Rating Scale weekly in the Italian sample and biweekly by the Quick Inventory of Depressive Symptomatology Clinician Rated in the STAR*D. Logistic regression was used to investigate possible predictors of early response and the Bonferroni correction was applied. In the STAR*D, higher levels of baseline core depressive symptoms (Bech subscale) were associated with early response (p=0.00017), as well as lower baseline insomnia (p=0.003) and higher work and social functioning (p=0.001). In the Italian sample none of these variables were associated with the phenotype, but a non significant trend of lower baseline quality of life (p=0.078) was observed in late remitters. In the STAR*D late responders reported higher levels of antidepressant induced side effects, especially difficulty in sleeping (p=5.68e-13), with a non significant trend in the same direction in the Italian sample (p=0.09). The identification of late versus early antidepressant responders at the beginning of the treatment may be useful to guide therapeutic choices in clinical settings.
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Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013; 14:334-85. [PMID: 23879318 DOI: 10.3109/15622975.2013.804195] [Citation(s) in RCA: 382] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. METHODS The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. RESULTS This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. CONCLUSIONS To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
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Gilaberte I, Romera I, Perez-Sola V, Menchon JM, Schacht A. Different levels of lack of improvement at 4 weeks of escitalopram treatment as predictors of poor 8-week outcome in MDD. J Affect Disord 2013; 146:433-7. [PMID: 22921481 DOI: 10.1016/j.jad.2012.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 07/26/2012] [Accepted: 07/26/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Several post-hoc studies have shown that lack of early improvement reduces the chance of later response or remission. This post-hoc analysis evaluates different cut-off points of non-improvement at 4 weeks of escitalopram treatment to predict 8-week non-response and non-remission. METHOD This study consisted of MDD patients with an absence of improvement (<30% reduction in baseline score of the HAMD-17) at Week 4 of escitalopram treatment (10mg/day) that continued escitalopram treatment (10-20mg/day) for a further 4-week period (n=251). Predictive, sensitivity and specificity values for the several definitions of non-improvement (≤ 25%, ≤ 20% and ≤ 15% reduction in the HAMD-17 baseline total score) at 4 weeks were calculated. RESULTS Overall, 70.1% (176/251) of patients did not achieve response at Week 8 and 84.5% (212/251) did not achieve remission. The predictive value for non-response was high (71.4-74.3%) for all cut-off points of non-improvement tested. The respective values for non-remission were placed between 85.0% and 87.2%. LIMITATIONS This was a post-hoc subgroup analysis. The only drug assessed was escitalopram. CONCLUSIONS Our data indicate that an absence of improvement, <30% reduction in the HAMD-17, after 4 weeks of escitalopram treatment should prompt clinicians to consider a change in treatment strategy. Similar findings were previously reported for other antidepressants.
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Romera I, Pérez V, Menchón JM, Schacht A, Papen R, Neuhauser D, Abbar M, Picard H, Gilaberte I. Early vs. conventional switching of antidepressants in patients with MDD and moderate to severe pain: a double-blind randomized study. J Affect Disord 2012; 143:47-55. [PMID: 22858211 DOI: 10.1016/j.jad.2012.05.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/17/2012] [Accepted: 05/17/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Concomitant painful physical symptoms in depressive patients frequently impair functioning and failure to treat these symptoms may adversely impact treatment outcomes of depression. Early vs. conventional switch of antidepressants were compared in patients with major depressive disorder (MDD) and moderate to severe pain. METHOD Pre-specified subgroup analysis of a 16-week, randomized, double-blind clinical study on MDD patients with >30 mm overall pain visual analog scale (VAS). Patients not achieving 30% reduction Hamilton Depression Rating Scale (HAM-D) after 4 weeks escitalopram (10 mg/day) were randomized to duloxetine 60-120 mg/day (early switch) or continued on escitalopram (conventional switch) with non-responders at week 8 switching to duloxetine. Endpoints were time to confirmed response and remission, VAS pain severity, and Sheehan disability scale (SDS). Switch strategies were compared using Kaplan-Meier, logistic regression, and repeated measures analyses. RESULTS No differences between early and conventional switching were found in time to confirmed response after randomization (3.9 vs. 4.1 weeks, p=0.511) or remission (6.0 vs. 8.0 weeks, p=0.238). Significantly lower VAS mean pain levels at for overall pain, headache, back pain, shoulder pain, interference with daily activities, and time being awake in pain were found for patients in the early switching group. Time to achieving normal functioning (SDS total score <6) was shorter in the early switching group (p=0.042). Safety results were comparable between switch strategies. CONCLUSIONS In MDD patients with moderate to severe painful physical symptoms not improving after 4 weeks of treatment with escitalopram, an earlier switch to duloxetine may lead to better pain and functional outcomes.
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Affiliation(s)
- Irene Romera
- Medical Department, Eli Lilly and Company, Madrid 28108, Spain.
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Abstract
The effective treatment of depression in people with bipolar disorder remains a clinical challenge. The role of antidepressant medication in treating bipolar depression has been controversial. While early studies and meta-analyses supported a role for antidepressant medication, more recent, high quality randomized controlled trials in bipolar depression have generally not demonstrated efficacy for antidepressant medications. Although the risk of affective switch and long-term de-stabilization remains a concern when using antidepressant medications in bipolar disorder, the magnitude of this risk has been difficult to ascertain with confidence. Maintenance use of antidepressant medication has generally not demonstrated a favorable risk-benefit ratio. Future studies should explore the patient characteristics and response patterns that predict a more favorable response profile to antidepressants amongst patients with bipolar disorder so that the medications can be rationally used in those who are most likely to benefit.
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Affiliation(s)
- Michelle M Sidor
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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