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Xiao J, Adkinson JA, Myers J, Allawala AB, Mathura RK, Pirtle V, Najera R, Provenza NR, Bartoli E, Watrous AJ, Oswalt D, Gadot R, Anand A, Shofty B, Mathew SJ, Goodman WK, Pouratian N, Pitkow X, Bijanki KR, Hayden B, Sheth SA. Beta activity in human anterior cingulate cortex mediates reward biases. Nat Commun 2024; 15:5528. [PMID: 39009561 PMCID: PMC11250824 DOI: 10.1038/s41467-024-49600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/07/2024] [Indexed: 07/17/2024] Open
Abstract
The rewards that we get from our choices and actions can have a major influence on our future behavior. Understanding how reward biasing of behavior is implemented in the brain is important for many reasons, including the fact that diminution in reward biasing is a hallmark of clinical depression. We hypothesized that reward biasing is mediated by the anterior cingulate cortex (ACC), a cortical hub region associated with the integration of reward and executive control and with the etiology of depression. To test this hypothesis, we recorded neural activity during a biased judgment task in patients undergoing intracranial monitoring for either epilepsy or major depressive disorder. We found that beta (12-30 Hz) oscillations in the ACC predicted both associated reward and the size of the choice bias, and also tracked reward receipt, thereby predicting bias on future trials. We found reduced magnitude of bias in depressed patients, in whom the beta-specific effects were correspondingly reduced. Our findings suggest that ACC beta oscillations may orchestrate the learning of reward information to guide adaptive choice, and, more broadly, suggest a potential biomarker for anhedonia and point to future development of interventions to enhance reward impact for therapeutic benefit.
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Affiliation(s)
- Jiayang Xiao
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Joshua A Adkinson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - John Myers
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | | | - Raissa K Mathura
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Victoria Pirtle
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Ricardo Najera
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Nicole R Provenza
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Eleonora Bartoli
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Andrew J Watrous
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Denise Oswalt
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Adrish Anand
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Ben Shofty
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84112, USA
| | - Sanjay J Mathew
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Wayne K Goodman
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Nader Pouratian
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Xaq Pitkow
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, 77030, USA
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, 77005, USA
- Center for Neuroscience and Artificial Intelligence, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Kelly R Bijanki
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Benjamin Hayden
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, 77005, USA.
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Remore LG, Tolossa M, Wei W, Karnib M, Tsolaki E, Rifi Z, Bari AA. Deep Brain Stimulation of the Medial Forebrain Bundle for Treatment-Resistant Depression: A Systematic Review Focused on the Long-Term Antidepressive Effect. Neuromodulation 2024; 27:690-700. [PMID: 37115122 DOI: 10.1016/j.neurom.2023.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/11/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Major depression affects millions of people worldwide and has important social and economic consequences. Since up to 30% of patients do not respond to several lines of antidepressive drugs, deep brain stimulation (DBS) has been evaluated for the management of treatment-resistant depression (TRD). The superolateral branch of the medial forebrain bundle (slMFB) appears as a "hypothesis-driven target" because of its role in the reward-seeking system, which is dysfunctional in depression. Although initial results of slMFB-DBS from open-label studies were promising and characterized by a rapid clinical response, long-term outcomes of neurostimulation for TRD deserve particular attention. Therefore, we performed a systematic review focused on the long-term outcome of slMFB-DBS. MATERIALS AND METHODS A literature search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was conducted to identify all studies reporting changes in depression scores after one-year follow-up and beyond. Patient, disease, surgical, and outcome data were extracted for statistical analysis. The Montgomery-Åsberg Depression Rating Scale (ΔMADRS) was used as the clinical outcome, defined as percentage reduction from baseline to follow-up evaluation. Responders' and remitters' rates were also calculated. RESULTS From 56 studies screened for review, six studies comprising 34 patients met the inclusion criteria and were analyzed. After one year of active stimulation, ΔMADRS was 60.7% ± 4%; responders' and remitters' rates were 83.8% and 61.5%, respectively. At the last follow-up, four to five years after the implantation, ΔMADRS reached 74.7% ± 4.6%. The most common side effects were stimulation related and reversible with parameter adjustments. CONCLUSIONS slMFB-DBS appears to have a strong antidepressive effect that increases over the years. Nevertheless, to date, the overall number of patients receiving implantations is limited, and the slMFB-DBS surgical technique seems to have an important impact on the clinical outcome. Further multicentric studies in a larger population are needed to confirm slMFB-DBS clinical outcomes.
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Affiliation(s)
- Luigi Gianmaria Remore
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; University of Milan "La Statale," Milan, Italy.
| | - Meskerem Tolossa
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Wexin Wei
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Evangelia Tsolaki
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Ziad Rifi
- University of California Los Angeles, Los Angeles, CA, USA
| | - Ausaf Ahmad Bari
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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3
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Nicolini ME, Jardas EJ, Zarate CA, Gastmans C, Kim SYH. Irremediability in psychiatric euthanasia: examining the objective standard. Psychol Med 2023; 53:5729-5747. [PMID: 36305567 PMCID: PMC10482705 DOI: 10.1017/s0033291722002951] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and 'according to current medical understanding'. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking. METHODS Using treatment-resistant depression (TRD) as a test case, through a scoping review in PubMed, we analyzed the state-of-the-art evidence for whether clinicians can accurately predict individual long-term outcome and single out irremediable cases, by examining the following questions: (1) What is the definition of TRD; (2) What are group-level long-term outcomes of TRD; and (3) Can clinicians make accurate individual outcome predictions in TRD? RESULTS A uniform definition of TRD is lacking, with over 150 existing definitions, mostly focused on psychopharmacological research. Available yet limited studies about long-term outcomes indicate that a majority of patients with long-term TRD show significant improvement over time. Finally, evidence about individual predictions in TRD using precision medicine is growing, but methodological shortcomings and varying predictive accuracies pose important challenges for its implementation in clinical practice. CONCLUSION Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with TRD. This means that the objective standard for irremediability cannot be met, with implications for policy and practice of psychiatric EAS.
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Affiliation(s)
- Marie E Nicolini
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland 20892, USA
- Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001, 3000 Leuven, Belgium
| | - E J Jardas
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland 20892, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, Experimental Therapeutics and Pathophysiology Branch, National Institutes of Mental Health, 6001 Executive Boulevard, Room 6200, MSC 9663, Bethesda, MD 20892, USA
| | - Chris Gastmans
- Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001, 3000 Leuven, Belgium
| | - Scott Y H Kim
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland 20892, USA
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Kern DM, Canuso CM, Daly E, Johnson JC, Fu DJ, Doherty T, Blauer‐Peterson C, Cepeda MS. Suicide-specific mortality among patients with treatment-resistant major depressive disorder, major depressive disorder with prior suicidal ideation or suicide attempts, or major depressive disorder alone. Brain Behav 2023; 13:e3171. [PMID: 37475597 PMCID: PMC10454258 DOI: 10.1002/brb3.3171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 06/20/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND The impact of treatment-resistant depression (TRD) or prior suicidal ideation/suicide attempt (SI/SA) on mortality by suicide among patients with major depressive disorder (MDD) is not well known. This retrospective, observational, descriptive cohort study characterized real-world rates of suicide-specific mortality among patients with MDD with or without TRD or SI/SA. METHODS Adult patients with MDD among commercially insured and Medicare enrollees in Optum Research Database were included and assigned to three cohorts: those with treatment-resistant MDD (TRD), those with MDD and SI/SA (MDD+SI/SA), and those with MDD without TRD or SI/SA (MDD alone). Suicide-specific mortality was obtained from the National Death Index. The effects of demographic characteristics and SI/SA in the year prior to the end of observation on suicide-specific mortality were assessed. RESULTS For the 139,753 TRD, 85,602 MDD+SI/SA, and 572,098 MDD alone cohort patients, mean age ranged from 55 to 59 years and the majority were female. At baseline, anxiety disorders were present in 53.92%, 44.11%, and 21.72% of patients with TRD, MDD+SI/SA, and MDD alone, respectively. Suicide-mortality rates in the three cohorts were 0.14/100 person-years for TRD, 0.27/100 person-years for MDD+SI/SA, and 0.04/100 person-years for MDD alone. SI/SA during the year prior to the end of observation, younger age, and male sex were associated with increased suicide risk. CONCLUSIONS Patients with TRD and MDD+SI/SA have a heightened risk of mortality by suicide compared with patients with MDD alone. Suicide rates were higher in patients with recent history versus older or no history of SI/SA, men versus women, and those of young age versus older age.
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Affiliation(s)
- David M. Kern
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUnited States
| | - Carla M. Canuso
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUnited States
| | - Ella Daly
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUnited States
| | | | - Dong Jing Fu
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUnited States
| | - Teodora Doherty
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUnited States
| | | | - M. Soledad Cepeda
- Department of EpidemiologyJanssen Research & DevelopmentTitusvilleNew JerseyUnited States
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Fennema D, Barker GJ, O'Daly O, Duan S, Carr E, Goldsmith K, Young AH, Moll J, Zahn R. Self-blame-selective hyper-connectivity between anterior temporal and subgenual cortices predicts prognosis in major depressive disorder. Neuroimage Clin 2023; 39:103453. [PMID: 37352570 PMCID: PMC10336192 DOI: 10.1016/j.nicl.2023.103453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Self-blame-related fMRI measures were shown to predict subsequent recurrence in remitted major depressive disorder (MDD). Their role in current MDD, however, is unknown. We hypothesised that these neural signatures reflect a highly recurrent but remitting course of MDD and therefore predict favourable outcomes over a four-month follow-up period in current MDD. METHODS Forty-five participants with current MDD and non-responders to at least two serotonergic antidepressants, were encouraged to optimise their medication and followed up after receiving four months of primary care treatment-as-usual. Prior to their medication review, participants completed an fMRI paradigm in which they viewed self- and other-blame emotion-evoking statements. Thirty-nine participants met pre-defined fMRI data minimum quality thresholds. Psychophysiological interaction analysis was used to determine baseline connectivity of the right superior anterior temporal lobe (RSATL), with an a priori BA25 region-of-interest for self-blaming vs other-blaming emotions, using Quick Inventory of Depressive Symptomatology (16-item) percentage change as a covariate. RESULTS We corroborated our pre-registered hypothesis that a favourable clinical outcome was associated with higher self-blame-selective RSATL-BA25 connectivity (Family-Wise Error-corrected p <.05 over the a priori BA25 region-of-interest; rs(34) = -0.47, p =.005). This generalised to the sample including participants with suboptimal fMRI quality (rs(39) = -0.32, p =.05). CONCLUSIONS This study shows that neural signatures of overgeneralised self-blame are relevant for prognostic stratification of current treatment-resistant MDD. Future studies need to confirm whether this neural signature indeed represents a trait-like feature of a fully remitting subtype of MDD, or whether it is also modulated by depressive state and related to treatment effects.
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Affiliation(s)
- Diede Fennema
- Centre of Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, Centre for Affective Disorders, King's College London, London, UK
| | - Gareth J Barker
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Owen O'Daly
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Suqian Duan
- Centre of Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, Centre for Affective Disorders, King's College London, London, UK
| | - Ewan Carr
- Department of Biostatics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kimberley Goldsmith
- Department of Biostatics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Allan H Young
- Centre of Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, Centre for Affective Disorders, King's College London, London, UK; National Service for Affective Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Jorge Moll
- Cognitive and Behavioural Neuroscience Unit, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
| | - Roland Zahn
- Centre of Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, Centre for Affective Disorders, King's College London, London, UK; Cognitive and Behavioural Neuroscience Unit, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil; National Service for Affective Disorders, South London and Maudsley NHS Foundation Trust, London, UK.
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Pigato G, Rosson S, Bresolin N, Toffanin T, Sambataro F, Olivo D, Perini G, Causin F, Denaro L, Landi A, D'Avella D. Vagus Nerve Stimulation in Treatment-Resistant Depression: A Case Series of Long-Term Follow-up. J ECT 2023; 39:23-27. [PMID: 35815853 DOI: 10.1097/yct.0000000000000869] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Vagus nerve stimulation (VNS) has been shown to be effective for treatment-resistant depression (TRD). However, long-term (>5 years) studies on the efficacy and tolerability of this treatment have been lacking. Here, we report a long-term clinical follow-up of 5 patients with severe and long-standing TRD, who received a VNS implant. METHODS Of the initial 6 patients with TRD implanted with VNS at our center, 5 of them were followed for 6 to 12 years after implantation. Primary efficacy outcomes were clinical response and improved functioning at follow-up visits. The primary safety outcome was all-cause discontinuation, and the secondary safety outcomes were the number and the severity of adverse events. RESULTS The VNS implant was associated with a sustained response (>10 years) in terms of clinical response and social, occupational, and psychological functioning in 3 patients. Two patients dropped out after 6 and 7 years of treatment, respectively. Vagus nerve stimulation was well tolerated by all patients, who reported only mild adverse effects. One patient, who discontinued concomitant drug treatment, had a hypomanic episode in the 10th year of treatment. The parameters of the VNS device were fine-tuned when life stressors or symptom exacerbation occurred. CONCLUSIONS Our case series showed that VNS can have long-term and durable effectiveness in patients with severe multiepisode chronic depression, and this could be associated with its neuroplastic effects in the hippocampus. In light of good general tolerability, our findings support VNS as a viable treatment option for TRD.
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Affiliation(s)
| | | | | | - Tommaso Toffanin
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara
| | | | - Daniele Olivo
- Department of Neuroscience, University of Padova, Padua
| | | | | | - Luca Denaro
- Department of Neuroscience, University of Padova, Padua
| | - Andrea Landi
- Department of Neuroscience, University of Padova, Padua
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Effect of Peer Victimization on the Long-Term Mental Health Status among Adults Users of Intellectual Disability Services: A Longitudinal Follow-Up Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074196. [PMID: 35409878 PMCID: PMC8998512 DOI: 10.3390/ijerph19074196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/18/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Caregiving for mental health among people with intellectual disabilities (IDs) in the ID services was reported as insufficient. The purposes of this study were to investigate five types of peer victimization (PV) experiences among adults with ID using ID services, and to gain a deeper understanding of the influence of PV experience on adults with ID’s long-term mental health status. A one-year longitudinal follow-up study was conducted from eight long-term care ID services (n = 176). Logistic regression analysis was applied to variables comprising personal characteristics, various types of PV experience and polyvictimization to predict period prevalence of psychiatric symptoms. The data indicated that nearly one-third of individuals with ID experienced at least one psychiatric symptom. The three most common psychiatric symptoms prevalent after one year were adjustment disorder, anxiety disorder, and somatoform disorder. Over the 1-year study period, approximately 40% of adults with ID reported experiencing PV. The most frequently reported types of PV were physical force (26%) and verbal victimization (22%). Polyvictimization was experienced by approximately a quarter of adults with ID. The findings suggest that PV is a common experience among adults in ID services. Thus, for a clearer understanding of mental health risks, caregivers should pay attention to adults with ID who experienced PV.
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When depression is difficult to treat. Eur Neuropsychopharmacol 2022; 56:89-91. [PMID: 34991000 DOI: 10.1016/j.euroneuro.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 12/28/2022]
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Hollunder B, Rajamani N, Siddiqi SH, Finke C, Kühn AA, Mayberg HS, Fox MD, Neudorfer C, Horn A. Toward personalized medicine in connectomic deep brain stimulation. Prog Neurobiol 2022; 210:102211. [PMID: 34958874 DOI: 10.1016/j.pneurobio.2021.102211] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 02/08/2023]
Abstract
At the group-level, deep brain stimulation leads to significant therapeutic benefit in a multitude of neurological and neuropsychiatric disorders. At the single-patient level, however, symptoms may sometimes persist despite "optimal" electrode placement at established treatment coordinates. This may be partly explained by limitations of disease-centric strategies that are unable to account for heterogeneous phenotypes and comorbidities observed in clinical practice. Instead, tailoring electrode placement and programming to individual patients' symptom profiles may increase the fraction of top-responding patients. Here, we propose a three-step, circuit-based framework with the aim of developing patient-specific treatment targets that address the unique symptom constellation prevalent in each patient. First, we describe how a symptom network target library could be established by mapping beneficial or undesirable DBS effects to distinct circuits based on (retrospective) group-level data. Second, we suggest ways of matching the resulting symptom networks to circuits defined in the individual patient (template matching). Third, we introduce network blending as a strategy to calculate optimal stimulation targets and parameters by selecting and weighting a set of symptom-specific networks based on the symptom profile and subjective priorities of the individual patient. We integrate the approach with published literature and conclude by discussing limitations and future challenges.
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Affiliation(s)
- Barbara Hollunder
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Nanditha Rajamani
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Carsten Finke
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany; NeuroCure Cluster of Excellence, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Helen S Mayberg
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael D Fox
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA
| | - Clemens Neudorfer
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas Horn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Raatikainen I, Mäntyselkä P, Heinonen A, Vanhala M, Kautiainen H, Koponen H, Korniloff K. Does baseline leisure-time physical activity level predict future depressive symptoms or physical activity among depressive patients? Findings from a Finnish five-year cohort study. Nord J Psychiatry 2021; 75:356-361. [PMID: 33380252 DOI: 10.1080/08039488.2020.1862296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aims of this study were to investigate whether baseline leisure-time physical activity (LTPA) is associated with future recovery from depression among patients with a depression diagnosis and whether baseline LTPA is associated with total physical activity after five years of follow-up. METHODS A total of 258 patients aged ≥35 years with clinically confirmed depression at baseline participated. The study was conducted between 2008 and 2016 in municipalities within the Central Finland Hospital District. Depressive symptoms (DS) were determined with the Beck Depression Inventory (BDI) with a cutoff score ≥10, and depression diagnoses were confirmed by the Mini-International Neuropsychiatric Interview (MINI). Blood pressure and anthropometric parameters were measured and blood samples for glucose and lipid determinations were drawn at baseline. LTPA, physical activity, and other social and clinical factors were captured by standard self-administered questionnaires at baseline and the five-year follow-up point. RESULTS Of the 258 patients, 76 (29%) had DS at follow-up. Adjusted odds ratio (OR) for future DS was 1.43 (confidence interval [CI] 0.69-2.95) for participants with moderate LTPA and 0.92 (CI 0.42-2.00) for participants with high LTPA, compared with low LTPA at baseline. Higher baseline LTPA levels were associated with higher total physical activity in the future (β=0.14 [95% CI: 0.02-0.26] for linearity = 0.024). CONCLUSION Baseline LTPA did not affect the five-year prognosis of depression among depressed patients in a Finnish adult population. Because the baseline LTPA level predicted the future total physical activity, it could be included as a part of the overall health management and treatment of depression in clinical practices.
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Affiliation(s)
- Ilkka Raatikainen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland.,Assistive Technology Centre, Central Finland Health Care District, Jyväskylä, Finland
| | - Pekka Mäntyselkä
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Ari Heinonen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Mauno Vanhala
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland.,Folkhälsan Research Center, Helsinki, Finland
| | - Hannu Koponen
- Old Age Psychiatry, Department of Psychiatry, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Katariina Korniloff
- School of Health and Social Studies, JAMK University of Applied Sciences, Jyväskylä, Finland
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Shah D, Allen L, Zheng W, Madhavan SS, Wei W, LeMasters TJ, Sambamoorthi U. Economic Burden of Treatment-Resistant Depression among Adults with Chronic Non-Cancer Pain Conditions and Major Depressive Disorder in the US. PHARMACOECONOMICS 2021; 39:639-651. [PMID: 33904144 PMCID: PMC8425301 DOI: 10.1007/s40273-021-01029-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Major depressive disorder (MDD) and chronic non-cancer pain conditions (CNPC) often co-occur and exacerbate one another. Treatment-resistant depression (TRD) in adults with CNPC can amplify the economic burden. This study examined the impact of TRD on direct total and MDD-related healthcare resource utilization (HRU) and costs among commercially insured patients with CNPC and MDD in the US. METHODS The retrospective longitudinal cohort study employed a claims-based algorithm to identify adults with TRD from a US claims database (January 2007 to June 2017). Costs (2018 US$) and HRU were compared between patients with and without TRD over a 12-month period after TRD/non-TRD index date. Counterfactual recycled predictions from generalized linear models were used to examine associations between TRD and annual HRU and costs. Post-regression linear decomposition identified differences in patient-level factors between TRD and non-TRD groups that contributed to the excess economic burden of TRD. RESULTS Of the 21,180 adults with CNPC and MDD, 10.1% were identified as having TRD. TRD patients had significantly higher HRU, translating into higher average total costs (US$21,015TRD vs US$14,712No TRD) and MDD-related costs (US$1201TRD vs US$471No TRD) compared with non-TRD patients (all p < 0.001). Prescription drug costs accounted for 37.6% and inpatient services for 30.7% of the excess total healthcare costs among TRD patients. TRD patients had a significantly higher number of inpatient (incidence rate ratio [IRR] 1.30, 95% CI 1.14-1.47) and emergency room visits (IRR 1.21, 95% CI 1.10-1.34) than non-TRD patients. Overall, 46% of the excess total costs were explained by differences in patient-level characteristics such as polypharmacy, number of CNPC, anxiety, sleep, and substance use disorders between the TRD and non-TRD groups. CONCLUSION TRD poses a substantial direct economic burden for adults with CNPC and MDD. Excess healthcare costs may potentially be reduced by providing timely interventions for several modifiable risk factors.
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Affiliation(s)
- Drishti Shah
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, PO Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Lindsay Allen
- Health Policy, Management, and Leadership Department, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Wanhong Zheng
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Suresh S Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, PO Box 9510, Morgantown, WV, 26506-9510, USA
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Wenhui Wei
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, PO Box 9510, Morgantown, WV, 26506-9510, USA
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | - Traci J LeMasters
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, PO Box 9510, Morgantown, WV, 26506-9510, USA
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, PO Box 9510, Morgantown, WV, 26506-9510, USA
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
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Fornaro M, Fusco A, Novello S, Mosca P, Anastasia A, De Blasio A, Iasevoli F, de Bartolomeis A. Predictors of Treatment Resistance Across Different Clinical Subtypes of Depression: Comparison of Unipolar vs. Bipolar Cases. Front Psychiatry 2020; 11:438. [PMID: 32670098 PMCID: PMC7326075 DOI: 10.3389/fpsyt.2020.00438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Treatment-resistant depression (TRD) and treatment-resistant bipolar depression (TRBD) poses a significant clinical and societal burden, relying on different operational definitions and treatment approaches. The detection of clinical predictors of resistance is elusive, soliciting clinical subtyping of the depressive episodes, which represents the goal of the present study. METHODS A hundred and thirty-one depressed outpatients underwent psychopathological evaluation using major rating tools, including the Hamilton Rating Scale for Depression, which served for subsequent principal component analysis, followed-up by cluster analysis, with the ultimate goal to fetch different clinical subtypes of depression. RESULTS The cluster analysis identified two clinically interpretable, yet distinctive, groups among 53 bipolar (resistant cases = 15, or 28.3%) and 78 unipolar (resistant cases = 20, or 25.6%) patients. Among the MDD patients, cluster "1" included the following components: "Psychic symptoms, depressed mood, suicide, guilty, insomnia" and "genitourinary, gastrointestinal, weight loss, insight". Altogether, with broadly defined "mixed features," this latter cluster correctly predicted treatment outcome in 80.8% cases of MDD. The same "broadly-defined" mixed features of depression (namely, the standard Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition-DSM-5-specifier plus increased energy, psychomotor activity, irritability) correctly classified 71.7% of BD cases, either as TRBD or not. LIMITATIONS Small sample size and high rate of comorbidity. CONCLUSIONS Although relying on different operational criteria and treatment history, TRD and TRBD seem to be consistently predicted by broadly defined mixed features among different clinical subtypes of depression, either unipolar or bipolar cases. If replicated by upcoming studies to encompass also biological and neuropsychological measures, the present study may aid in precision medicine and informed pharmacotherapy.
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Affiliation(s)
- Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy.,Polyedra Research Group, Teramo, Italy
| | - Andrea Fusco
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy
| | - Stefano Novello
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy
| | - Pierluigi Mosca
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy
| | | | - Antonella De Blasio
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy
| | - Felice Iasevoli
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy
| | - Andrea de Bartolomeis
- Laboratory of Molecular and Translational Psychiatry, Unit of Treatment-Resistant Psychosis, Section of Psychiatry, University of Naples Federico II, Naples, Italy
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13
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Evenblij K, Pasman HRW, van der Heide A, van Delden JJM, Onwuteaka-Philipsen BD. Public and physicians' support for euthanasia in people suffering from psychiatric disorders: a cross-sectional survey study. BMC Med Ethics 2019; 20:62. [PMID: 31510976 PMCID: PMC6737595 DOI: 10.1186/s12910-019-0404-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 09/02/2019] [Indexed: 01/09/2023] Open
Abstract
Background Although euthanasia and assisted suicide (EAS) in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients. Methods A survey was distributed amongst a random sample of Dutch 2641 citizens (response 75%) and 3000 physicians (response 52%). Acceptance and conceivability of performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed. Results Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority (> 65%) of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered. Conclusion The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria. Supplementary information Supplementary information accompanies this paper at 10.1186/s12910-019-0404-8.
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Affiliation(s)
- Kirsten Evenblij
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands
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14
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Crowe E, Daly M, Delaney L, Carroll S, Malone KM. The intra-day dynamics of affect, self-esteem, tiredness, and suicidality in Major Depression. Psychiatry Res 2019; 279:98-108. [PMID: 29661498 DOI: 10.1016/j.psychres.2018.02.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 12/02/2017] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Abstract
Despite growing interest in the temporal dynamics of Major Depressive Disorder (MDD), we know little about the intra-day fluctuations of key symptom constructs. In a study of momentary experience, the Experience Sampling Method captured the within-day dynamics of negative affect, positive affect, self-esteem, passive suicidality, and tiredness across clinical MDD (N= 31) and healthy control groups (N= 33). Ten symptom measures were taken per day over 6 days (N= 2231 observations). Daily dynamics were modeled via intra-day time-trends, variability, and instability in symptoms. MDD participants showed significantly increased variability and instability in negative affect, positive affect, self-esteem, and suicidality. Significantly different time-trends were found in positive affect (increased diurnal variation and an inverted U-shaped pattern in MDD, compared to a positive linear trend in controls) and tiredness (decreased diurnal variation in MDD). In the MDD group only, passive suicidality displayed a negative linear trend and self-esteem displayed a quadratic inverted U trend. MDD and control participants thus showed distinct dynamic profiles in all symptoms measured. As well as the overall severity of symptoms, intra-day dynamics appear to define the experience of MDD symptoms.
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Affiliation(s)
- Eimear Crowe
- UCD School of Medicine, University College Dublin, Ireland; Behavioural Science Centre, Stirling Management School, University of Stirling, United Kingdom; Institute of Health and Wellbeing, College of Veterinary, Medical and Life Sciences, University of Glasgow, Glasgow, United Kingdom.
| | - Michael Daly
- Behavioural Science Centre, Stirling Management School, University of Stirling, United Kingdom; UCD Geary Institute, University College Dublin, Ireland
| | - Liam Delaney
- Behavioural Science Centre, Stirling Management School, University of Stirling, United Kingdom; UCD Geary Institute, University College Dublin, Ireland
| | - Susan Carroll
- UCD School of Medicine, University College Dublin, Ireland; Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Kevin M Malone
- UCD School of Medicine, University College Dublin, Ireland
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15
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Wu B, Cai Q, Sheehan JJ, Benson C, Connolly N, Alphs L. An episode level evaluation of the treatment journey of patients with major depressive disorder and treatment-resistant depression. PLoS One 2019; 14:e0220763. [PMID: 31393922 PMCID: PMC6687173 DOI: 10.1371/journal.pone.0220763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/23/2019] [Indexed: 12/21/2022] Open
Abstract
Background Many patients with major depressive disorder (MDD) fail to respond to antidepressant (AD) pharmacotherapy. The objectives of this study were to characterize MDD and treatment-resistant depression (TRD) at the level of pharmacologically treated episodes and to describe the sequential treatment patterns by lines of therapy (LOT) in the first two episodes. Methods Adults (≥18 years of age) with continuous enrollment ≥12 months before and after the first MDD diagnosis and treated with an AD, with or without an MDD-indicated antipsychotic (AP), were identified (1/1/2010-12/31/2015). The MDD episode started on the date of MDD diagnosis that was preceded by a clean period without any MDD diagnosis. The MDD episode ended on the last MDD diagnosis or the end of the days’ supply of AD/AP medication, whichever came last. TRD was defined as an MDD episode with ≥3 AD/AP regimens. Measured outcomes included episode duration, number of LOT, relapse hospitalization, and sequential treatment patterns of MDD episode stratified by TRD and non-TRD episodes. Results Of 48,440 patients who received AD/AP in the 1st MDD episode, 3,317 (6.8%) of episodes were considered TRD. Mean duration of 1st TRD episodes was 571 days, mean number of AD/AP LOTs was 3.47, and 13.7% involved relapse hospitalization. Mean duration of 1st non-TRD episodes was 200 days, mean number of AD/AP LOTs was 1.21, and 9.6% involved relapse hospitalization. Among 1st MDD episodes, 25.5% had a second LOT; 7.3% had a third LOT. Most patients received selective serotonin reuptake inhibitors (SSRIs) as the first LOT (63.0%), and the plurality of regimens were SSRIs in second (44.9%) and third LOT (41.1%). Conclusions Compared to non-TRD episodes, TRD episodes were longer and more often involved relapse hospitalizations. SSRIs were the most common treatment; treatment changes and potential treatment unresponsiveness were frequent among MDD patients.
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Affiliation(s)
- Bingcao Wu
- Janssen Scientific Affairs, LLC, Titusville, NJ, United States of America
| | - Qian Cai
- Janssen Scientific Affairs, LLC, Titusville, NJ, United States of America
| | - John J. Sheehan
- Janssen Scientific Affairs, LLC, Titusville, NJ, United States of America
- * E-mail:
| | - Carmela Benson
- Janssen Scientific Affairs, LLC, Titusville, NJ, United States of America
| | - Nancy Connolly
- Janssen Scientific Affairs, LLC, Titusville, NJ, United States of America
| | - Larry Alphs
- Janssen Scientific Affairs, LLC, Titusville, NJ, United States of America
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16
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Strawbridge R, Hodsoll J, Powell TR, Hotopf M, Hatch SL, Breen G, Cleare AJ. Inflammatory profiles of severe treatment-resistant depression. J Affect Disord 2019; 246:42-51. [PMID: 30578945 DOI: 10.1016/j.jad.2018.12.037] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/29/2018] [Accepted: 12/16/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment-resistant depression (TRD) contributes substantially to the burden of mood disorders and is undoubtedly an important subpopulation in whom there are clear unmet treatment needs. Despite a paucity of research focusing specifically on TRD, recent studies indicate that inflammatory activity may be particularly elevated in these patients. METHODS 36 patients with TRD were investigated longitudinally before and after undertaking a specialist inpatient treatment program. 27 inflammatory proteins were compared between patients and a matched sample of non-depressed controls, as well as between treatment responders and non-responders. Treatment outcomes were calculated from depression severity scores before and after admission, and at a long-term follow-up 3-12 months after discharge. RESULTS TRD patients had higher levels of numerous inflammatory proteins than controls, and elevated interleukins 6 and 8, tumour necrosis factor, c-reactive protein and macrophage inflammatory protein-1 were associated with poorer treatment outcomes. A separate set of proteins (either anti-inflammatory in nature or attenuated at baseline) showed increases during treatment, regardless of clinical response. Participants with the greatest elevations in inflammation tended to be older, more cognitively impaired and more treatment-resistant at baseline. LIMITATIONS The small sample and large number of comparisons examined in this study must be taken into account when interpreting these results. CONCLUSIONS However, this study provides empirical support for theories that more severe, chronic or treatment-resistant depressive disorders are associated with dysregulated inflammatory activity. If a predictor or predictors of response in TRD are established, improved and targeted care might be more reliably provided to this vulnerable population.
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Affiliation(s)
- Rebecca Strawbridge
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - John Hodsoll
- Department of Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Timothy R Powell
- Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; South London & Maudsley NHS Foundation Trust, London, UK
| | - Stephani L Hatch
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gerome Breen
- Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Anthony J Cleare
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; South London & Maudsley NHS Foundation Trust, London, UK
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17
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Evenblij K, Pasman HRW, Pronk R, Onwuteaka-Philipsen BD. Euthanasia and physician-assisted suicide in patients suffering from psychiatric disorders: a cross-sectional study exploring the experiences of Dutch psychiatrists. BMC Psychiatry 2019; 19:74. [PMID: 30782146 PMCID: PMC6381744 DOI: 10.1186/s12888-019-2053-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/11/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The medical-ethical dilemmas related to euthanasia and physician-assisted suicide (EAS) in psychiatric patients are highly relevant in an international context. EAS in psychiatric patients appears to become more frequent in the Netherlands. However, little is known about the experiences of psychiatrists with this practice. This study aims to estimate the incidence of EAS (requests) in psychiatric practice in The Netherlands and to describe the characteristics of psychiatric patients requesting EAS, the decision-making process and outcomes of these requests. METHODS In the context of the third evaluation of the Dutch Euthanasia Act, a cross-sectional study was performed between May and September 2016. A questionnaire was sent to a random sample of 500 Dutch psychiatrists. Of the 425 eligible psychiatrists 49% responded. Frequencies of EAS and EAS requests were estimated. Detailed information was asked about the most recent case in which psychiatrists granted and/or refused an EAS request, if any. RESULTS The total number of psychiatric patients explicitly requesting for EAS was estimated to be between 1100 and 1150 for all psychiatrists in a one year period from 2015 to 2016. An estimated 60 to 70 patients received EAS in this period. Nine psychiatrists described a case in which they granted an EAS request from a psychiatric patient. Five of these nine patients had a mood disorder. Three patients had somatic comorbidity. Main reasons to request EAS were 'depressive feelings' and 'suffering without prospect of improvement'. Sixty-six psychiatrists described a case in which they refused an EAS request. 59% of these patients had a personality disorder and 19% had somatic comorbidity. Main reasons to request EAS were 'depressive feelings' and 'desperate situations in several areas of life'. Most requests were refused because the due care criteria were not met. CONCLUSIONS Although the incidence of EAS in psychiatric patients increased over the past two decades, this practice remains relatively rare. This is probably due to the complexity of assessing the due care criteria in case of psychiatric suffering. Training and support may enable psychiatrists to address this sensitive issue in their work better.
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Affiliation(s)
- Kirsten Evenblij
- Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, P.O. Box 7057, 1007 Amsterdam, MB Netherlands
| | - H. Roeline W. Pasman
- Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, P.O. Box 7057, 1007 Amsterdam, MB Netherlands
| | - Rosalie Pronk
- Department of General Practice, section Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, P.O. Box 7057, 1007 Amsterdam, MB Netherlands
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18
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Olfson M, Amos TB, Benson C, McRae J, Marcus SC. Prospective Service Use and Health Care Costs of Medicaid Beneficiaries with Treatment-Resistant Depression. J Manag Care Spec Pharm 2018; 24:226-236. [PMID: 29485948 PMCID: PMC10398231 DOI: 10.18553/jmcp.2018.24.3.226] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although the clinical and health economic characteristics of commercially insured adults with treatment-resistant depression (TRD) have been well characterized, little is known about TRD in the Medicaid population. OBJECTIVE To describe clinical and health economic characteristics of adult Medicaid beneficiaries with TRD. METHODS Retrospective longitudinal cohort analyses were performed with Truven Health MarketScan Medicaid Database (2008-2014), focusing on adults with major depressive disorder (MDD) following an index antidepressant prescription. TRD was operationally defined as starting a third treatment regimen after 2 adequate regimens of antidepressants or augmentation therapy within 12 months of an index antidepressant prescription. Among patients with and without TRD, percentages with inpatient admissions, emergency department visits, and outpatient visits (all cause, mental health related, and depression related) were determined. Logistic regression models were used to examine associations between TRD status and use of inpatient, outpatient, and emergency services. Separate analyses were performed for the first and second year after the index antidepressant prescription. RESULTS Approximately one quarter (25.9%) of pharmacologically treated adults with MDD met criteria for TRD. In relation to MDD patients without TRD, patients with TRD were proportionately more likely to be older, male, and white. Compared with MDD patients without TRD, patients with TRD were also significantly more likely to receive inpatient care for any cause (31.0% vs. 21.6%; P < 0.001), a mental health-related reason (12.7% vs. 7.6%; P < 0.001), or depression (10.1% vs. 6.1%; P < 0.001) during the first year following their index antidepressant prescription. Over the second follow-up year, patients with TRD continued to be more likely than patients without TRD to receive inpatient care for any reason (26.7% vs. 19.5%; P < 0.001), a mental health-related reason (5.6% vs. 2.7%; P < 0.001), and depression (3.7% vs. 1.7%; P < 0.001). The mean health care costs of patients with TRD were also significantly higher than the costs of patients without TRD during the first year ($18,982 [SD ± $35,276] vs. $11,642 [SD ± $29,203]) and second year ($17,997 [SD ± $34,146] vs. $10,325 [SD ± $28,224]) following the index antidepressant prescription. CONCLUSIONS In the U.S. Medicaid program, adults with TRD have substantially and persistently higher health care costs than their counterparts who do not meet criteria for TRD. The service use and health care cost patterns of patients with TRD in the Medicaid program highlight challenges of developing interventions and care coordination strategies to meet their complex clinical needs. DISCLOSURES This project was sponsored by Janssen Scientific Affairs. Olfson received a grant from Janssen Scientific Affairs through Columbia University Medical Center. Amos and Benson are employees of Janssen Scientific Affairs. Marcus was paid by Janssen Scientific Affairs to provide consulting support for this study and reports fees from Sunovion Pharmaceuticals and Alkermes outside of this study. McRae was a fellow affiliated with Janssen Scientific Affairs during the development of this research and manuscript. Study concept and design were contributed by Amos, Olfson, Marcus, Benson, and McRae. Data analysis was performed by all the authors. The manuscript was primarily written by Olfson, along with the other authors, and revised by McRae, Benson, Amos, Marcus, and Olfson. A different data cut from the same database was presented previously at the 2017 Annual Meeting of the International Society for Pharmacoeconomics and Outcomes Research; May 20-24, 2017; Boston, MA; and the 2017 AcademyHealth Annual Research Meeting; June 25-27, 2017; New Orleans, LA.
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Affiliation(s)
- Mark Olfson
- 1 Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, New York, New York
| | - Tony B Amos
- 2 Health Economics and Outcomes Research, Janssen Scientific Affairs, Titusville, New Jersey
| | - Carmela Benson
- 2 Health Economics and Outcomes Research, Janssen Scientific Affairs, Titusville, New Jersey
| | - Jacquelyn McRae
- 2 Health Economics and Outcomes Research, Janssen Scientific Affairs, Titusville, New Jersey
| | - Steven C Marcus
- 3 School of Social Practice & Policy, University of Pennsylvania, Philadelphia
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Mergl R, Allgaier AK, Hautzinger M, Coyne JC, Hegerl U, Henkel V. One-year follow-up of a randomized controlled trial of sertraline and cognitive behavior group therapy in depressed primary care patients (MIND study). J Affect Disord 2018; 230:15-21. [PMID: 29355727 DOI: 10.1016/j.jad.2017.12.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 11/29/2017] [Accepted: 12/31/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The long-term course of symptoms in patients with mild-to-moderate depression is not well understood. A 12-month-follow-up analysis was performed on those participants from a randomized controlled 10-week trial (RCT, MIND-study), who had received either treatment with an antidepressant (sertraline) or a psychotherapeutic intervention (group cognitive-behavioral therapy (CBT)). METHODS The longitudinal interval follow-up evaluation (LIFE) was applied to 77 patients with mild-to moderate depression. The primary outcome was the number of weeks in the one-year follow-up period spent completely recovered from all depressive symptoms. Functional outcome was measured with the Global Assessment of Functioning (GAF) scale. Further outcomes were relapse and remission rates based on weekly psychiatric rating scales (PSR) and the number of weeks in the follow-up period during which patients had a depressive disorder or subthreshold symptoms of depression. RESULTS Patients with acute treatment (10 weeks) with SSRI and those with acute treatment with CBT (also 10 weeks) did not differ significantly concerning the number of weeks in the follow-up period in which they were completely recovered (primary outcome) (SSRI: 31.6 weeks (standard deviation (SD): 23.7), CBT: 27.8 weeks (SD: 24.3)). Sertraline was superior to CBT regarding GAF scores by trend (p = 0.06). LIMITATIONS The generalizability of the findings is limited by the moderate sample size and missing values (LIFE). CONCLUSIONS Sertraline and group CBT have similar anti-depressive effects in the long-term course of mild-to-moderate depression. Regarding long-term global functioning, sertraline seems to be slightly superior to CBT.
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Affiliation(s)
- Roland Mergl
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Semmelweisstr. 10, D-04103 Leipzig, Germany
| | - Antje-Kathrin Allgaier
- Department of Clinical Psychology, University of the Federal Armed Forces Munich, Werner-Heisenberg-Weg 39, D-85577 Neubiberg, Germany
| | - Martin Hautzinger
- Department of Psychology, Eberhard-Karls-University Tuebingen, Christophstr. 2, D-72072 Tuebingen, Germany
| | - James C Coyne
- Department of Health Psychology, UMCG, Groningen and University of Groningen, Groningen, The Netherlands
| | - Ulrich Hegerl
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Semmelweisstr. 10, D-04103 Leipzig, Germany.
| | - Verena Henkel
- Department of Psychiatry, Ludwig-Maximilians-University Munich, Nußbaumstr. 7, D-80336 Munich, Germany
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Nuñez NA, Comai S, Dumitrescu E, Ghabrash MF, Tabaka J, Saint-Laurent M, Vida S, Kolivakis T, Fielding A, Low N, Cervantes P, Booij L, Gobbi G. Psychopathological and sociodemographic features in treatment-resistant unipolar depression versus bipolar depression: a comparative study. BMC Psychiatry 2018; 18:68. [PMID: 29548306 PMCID: PMC5857132 DOI: 10.1186/s12888-018-1641-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Some authors have hypothesized that Treatment-Resistant Unipolar Depression (TRD-UP) should be considered within the bipolar spectrum disorders and that hidden bipolarity may be a risk factor for TRD-UP. However, there are neither studies comparing clinical and sociodemographic data of patients with TRD-UP versus Bipolar (BP) disorders nor are there any examining differences versus Bipolar type I (BP-I) and Bipolar type II (BP-II). METHODS Charts analysis was conducted on 194 patients followed at the Mood Disorders Clinic of the McGill University Health Center. Sociodemographic, clinical features and depression scales were collected from patients meeting DSM-IV criteria for TRD-UP (n = 100) and BP (n = 94). Binary logistic regression analysis was conducted to examine clinical predictors independently associated with the two disorders. RESULTS Compared to BP, TRD-UP patients exhibited greater severity of depression, prevalence of anxiety and panic disorders, melancholic features, Cluster-C personality disorders, later onset of depression and fewer hospitalizations. Binary logistic regression indicated that higher comorbidity with anxiety disorders, higher depression scale scores and lower global assessment of functioning (GAF) scores, and lower number of hospitalizations and psychotherapies differentiated TRD-UP from BP patients. We also found that the rate of unemployment and the number of hospitalizations for depression was higher in BP-I than in BP-II, while the rate of suicide attempts was lower in BP-I than in BP-II depressed patients. CONCLUSIONS These results suggest that TRD-UP constitutes a distinct psychopathological condition and not necessarily a prodromal state of BP depression.
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Affiliation(s)
- Nicolas A. Nuñez
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Stefano Comai
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000000417581884grid.18887.3eDivision of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Eduard Dumitrescu
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Maykel F. Ghabrash
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - John Tabaka
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Marie Saint-Laurent
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Stephen Vida
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Theodore Kolivakis
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Allan Fielding
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Nancy Low
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Pablo Cervantes
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Linda Booij
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0001 2292 3357grid.14848.31Department of Psychology, Concordia University and Sainte-Justine Hospital Research Center, University of Montréal, Montréal, QC Canada
| | - Gabriella Gobbi
- Department of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC, Canada. .,Department of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC, Canada.
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Husain MI, Strawbridge R, Stokes PR, Young AH. Anti-inflammatory treatments for mood disorders: Systematic review and meta-analysis. J Psychopharmacol 2017; 31:1137-1148. [PMID: 28858537 DOI: 10.1177/0269881117725711] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent studies suggest that anti-inflammatory medication may play a role in the treatment of mood disorders. AIMS The purpose of this study was to determine the efficacy of anti-inflammatory drugs in patients with major depressive disorder and bipolar disorder. METHOD The Cochrane Central Register of Controlled Trials, PubMed, EMBASE, PsychINFO and Clinicaltrials.gov were searched from inception until 15 April 2017 for completed and on-going randomized controlled trials of anti-inflammatory agents for major depressive disorder and bipolar disorder. Data from randomized controlled trials assessing the antidepressant and anti-manic effect of adjunctive mechanistically diverse anti-inflammatory agents were pooled to determine standard mean differences (SMDs) compared with placebo and/or treatment as usual. RESULTS Patients receiving anti-inflammatory agents showed lower post-treatment depressive symptom scores compared with those receiving placebo with a standard mean difference of -0.71 (six randomized controlled trials, n=214, 95% CI -1.24 to -0.17, p=0.009). Anti-inflammatory treatment was found to reduce post-treatment manic symptom scores with a standard mean difference of -0.72 (three randomized controlled trials, n=96, 95% CI -1.31 to -0.13, p=0.02). Anti-inflammatories did not show a statistically significant improvement in the secondary outcome measure (change in symptom scores from baseline to outcome). CONCLUSIONS Further high quality trials are needed before making recommendations for the routine clinical use of anti-inflammatories in the treatment of mood disorders.
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Affiliation(s)
- Muhammad I Husain
- 1 Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | | | - Paul Ra Stokes
- 2 Centre for Affective Disorders, King's College London, London, UK
| | - Allan H Young
- 2 Centre for Affective Disorders, King's College London, London, UK
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Dierickx S, Deliens L, Cohen J, Chambaere K. Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry 2017; 17:203. [PMID: 28641576 PMCID: PMC5481967 DOI: 10.1186/s12888-017-1369-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/23/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Euthanasia for people who are not terminally ill, such as those suffering from psychiatric disorders or dementia, is legal in Belgium under strict conditions but remains a controversial practice. As yet, the prevalence of euthanasia for people with psychiatric disorders or dementia has not been studied and little is known about the characteristics of the practice. This study aims to report on the trends in prevalence and number of euthanasia cases with a psychiatric disorder or dementia diagnosis in Belgium and demographic, clinical and decision-making characteristics of these cases. METHODS We analysed the anonymous databases of euthanasia cases reported to the Federal Control and Evaluation Committee Euthanasia from the implementation of the euthanasia law in Belgium in 2002 until the end of 2013. The databases we received provided the information on all euthanasia cases as registered by the Committee from the official registration forms. Only those with one or more psychiatric disorders or dementia and no physical disease were included in the analysis. RESULTS We identified 179 reported euthanasia cases with a psychiatric disorder or dementia as the sole diagnosis. These consisted of mood disorders (N = 83), dementia (N = 62), other psychiatric disorders (N = 22) and mood disorders accompanied by another psychiatric disorder (N = 12). The proportion of euthanasia cases with a psychiatric disorder or dementia diagnosis was 0.5% of all cases reported in the period 2002-2007, increasing from 2008 onwards to 3.0% of all cases reported in 2013. The increase in the absolute number of cases is particularly evident in cases with a mood disorder diagnosis. The majority of cases concerned women (58.1% in dementia to 77.1% in mood disorders). All cases were judged to have met the legal requirements by the Committee. CONCLUSIONS While euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder or dementia remains a comparatively limited practice in Belgium, its prevalence has risen since 2008. If, as this study suggests, people with psychiatric conditions or dementia are increasingly seeking access to euthanasia, the development of practice guidelines is all the more desirable if physicians are to respond adequately to these highly delicate requests.
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Affiliation(s)
- Sigrid Dierickx
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
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Mei Bai Y, Li CT, Chen MH, Kuang Yang Y. Self-Reported Graphic Personal and Social Performance Scale (SRG-PSP) for measuring functionality in patients with bipolar disorder. J Affect Disord 2017; 215:256-262. [PMID: 28343053 DOI: 10.1016/j.jad.2017.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/07/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The self-reported graphic version of the Personal and Social Performance Scale (SRG-PSP) is the first graphic, self-reported rating scale that assesses functioning, and its reliability and validity have been documented in patients with schizophrenia. This study investigated the validity of SRG-PSP in patients with bipolar disorder (BD). METHODS Patients with BD were recruited from psychiatric outpatient clinics, and assessed with the Young Mania Rating Scale (YMRS), the Montgomery-Åsberg Depression Rating Scale (MADRS), the Clinical Global Impression Scale (CGI)-Bipolar and CGI-Depression, the Positive and Negative Symptom Scale (PANSS), the Global assessment of function (GAF), and the PSP. All participants completed the self-rating questionnaires: the SRG-PSP, the 36-Item Short-Form Health Survey (SF-36), and the Sheehan disability Scale (SDS). RESULTS In total, 114 patients with BD were enrolled. The criterion-related validities between the SRG-PSP and the PSP were all significantly correlated with their counterparts. The global score of the SRG-PSP was significantly correlated with the scores of the YMRS, MADRS, PANSS, CGI-Depression, GAF, SF-36, and SDS. Three SRG-PSP domains (socially useful activities, personal and social relationships, and self-care) were negatively correlated with the scores of the MADRS, PANSS, CGI-depression, and SDS; and were positively correlated with the GAF, SF-36 scores. The disturbing and aggressive behavior domain was positively correlated with the scores of the YMRS, MADRS, PANSS, CGI-Bipolar, CGI-Depression, and SDS; and was negatively correlated with the GAF, SF-36 scores (all p<0.01). CONCLUSION The SRG-PSP is a validated self-reported scale for assessing functionality in patients with BD.
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Affiliation(s)
- Ya Mei Bai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Cheng-Ta Li
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Psychiatry, College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen Kuang Yang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
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Bewernick BH, Kayser S, Gippert SM, Switala C, Coenen VA, Schlaepfer TE. Deep brain stimulation to the medial forebrain bundle for depression- long-term outcomes and a novel data analysis strategy. Brain Stimul 2017; 10:664-671. [PMID: 28259544 DOI: 10.1016/j.brs.2017.01.581] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the supero-lateral branch of the medial forebrain bundle (slMFB) in treatment-resistant depression (TRD) is associated with acute antidepressant effects. OBJECTIVE Long-term clinical effects including changes in quality of life, side effects and cognition as well as long-term data covering four years are assessed. METHODS Eight TRD patients were treated with DBS bilateral to the slMFB. Primary outcome measure was a 50% reduction in Montgomery-Åsberg Depression Rating Scale (MADRS) (response) and remission (MADRS <10) at 12 months compared to baseline. Secondary measures were anxiety, general functioning, quality of life, safety and cognition assessed for 4 years. Data is reported as conventional endpoint-analysis and as area under the curve (AUC) timeline analysis. RESULTS Six of eight patients (75%) were responders at 12 months, four patients reached remission. Long-term results revealed a stable effect up to four years. Antidepressant efficacy was also reflected in the global assessment of functioning. Main side effect was strabismus at higher stimulation currents. No change in cognition was identified. AUC analysis revealed a significant reduction in depression for 7/8 patients in most months. CONCLUSIONS Long-term results of slMFB-DBS suggest acute and sustained antidepressant effect; timeline analysis may be an alternative method reflecting patient's overall gain throughout the study. Being able to induce a rapid and robust antidepressant effect even in a small, sample of TRD patients without significant psychiatric comorbidity, render the slMFB an attractive target for future studies.
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Affiliation(s)
| | - Sarah Kayser
- Department of Psychiatry and Psychotherapy, University of Bonn, Germany
| | - Sabrina M Gippert
- Department of Psychiatry and Psychotherapy, University of Bonn, Germany
| | - Christina Switala
- Department of Psychiatry and Psychotherapy, University of Bonn, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Germany
| | - Thomas E Schlaepfer
- Division of Interventional Biological Psychiatry, University Hospital Freiburg, Germany; Departments of Psychiatry and Mental Health, The Johns Hopkins University, Baltimore, MD, USA.
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Fischer S, Strawbridge R, Vives AH, Cleare AJ. Cortisol as a predictor of psychological therapy response in depressive disorders: systematic review and meta-analysis. Br J Psychiatry 2017; 210:105-109. [PMID: 27908897 DOI: 10.1192/bjp.bp.115.180653] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 07/26/2016] [Accepted: 08/23/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many patients with depressive disorders demonstrate resistance to psychological therapy. A frequent finding is hypothalamic-pituitary-adrenal (HPA) axis alterations. As cortisol is known to modulate cognitive processes, those patients may be less likely to profit from psychological therapy. AIMS To conduct a systematic review and meta-analysis on cortisol as a predictor of psychological therapy response. METHOD The Cochrane Library, EMBASE, MEDLINE and PsycINFO databases were searched. Records were included if they looked at patients with any depressive disorder engaging in psychological therapy, with a pre-treatment cortisol and a post-treatment symptom measure. RESULTS Eight articles satisfied our selection criteria. The higher the cortisol levels before starting psychological therapy, the more symptoms patients with depression experienced at the end of treatment and/or the smaller their symptom change. CONCLUSIONS Our findings suggest that patients with depression with elevated HPA functioning are less responsive to psychological therapy.
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Affiliation(s)
- Susanne Fischer
- Susanne Fischer, PhD, Rebecca Strawbridge, MSc, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Andres Herane Vives, MD, DPM, MSc, Universidad Católica del Norte, Coquimbo, Chile and Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Anthony J. Cleare, BSc, MBBS, FRCPsych, PhD, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rebecca Strawbridge
- Susanne Fischer, PhD, Rebecca Strawbridge, MSc, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Andres Herane Vives, MD, DPM, MSc, Universidad Católica del Norte, Coquimbo, Chile and Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Anthony J. Cleare, BSc, MBBS, FRCPsych, PhD, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Andres Herane Vives
- Susanne Fischer, PhD, Rebecca Strawbridge, MSc, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Andres Herane Vives, MD, DPM, MSc, Universidad Católica del Norte, Coquimbo, Chile and Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Anthony J. Cleare, BSc, MBBS, FRCPsych, PhD, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Anthony J Cleare
- Susanne Fischer, PhD, Rebecca Strawbridge, MSc, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Andres Herane Vives, MD, DPM, MSc, Universidad Católica del Norte, Coquimbo, Chile and Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Anthony J. Cleare, BSc, MBBS, FRCPsych, PhD, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Husain MI, Chaudhry IB, Hamirani MM, Minhas FA, Kazmi A, Hodsoll J, Haddad PM, Deakin JF, Husain N, Young AH. Minocycline and celecoxib as adjunctive treatments for bipolar depression: a study protocol for a multicenter factorial design randomized controlled trial. Neuropsychiatr Dis Treat 2017; 13:1-8. [PMID: 28031712 PMCID: PMC5182039 DOI: 10.2147/ndt.s115002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Evidence suggests that the use of anti-inflammatory agents may improve depressive symptoms in patients with bipolar affective disorder. However, there are few well-designed clinical trials demonstrating the efficacy of these newer treatment strategies. PATIENTS AND METHODS This is a multicenter, 3-month, randomized, placebo-controlled, double-blind, factorial design trial of minocycline and/or celecoxib added to TAU for the treatment of depressive symptoms in patients experiencing a DSM-5 bipolar I or II disorder and a current major depressive episode. A total of 240 participants will undergo screening and randomization followed by four assessment visits. The primary outcome measure will be mean change from baseline to week 12 on the Hamilton Depression Scale scores. Clinical assessments using the Clinical Global Impression scale, Patient Health Questionnaire-9, and the Generalized Anxiety Disorder 7-item scale will be carried out at every visit as secondary outcomes. Side-effect checklists will be used to monitor the adverse events at each visit. Complete blood count and plasma C-reactive protein will be measured at baseline and at the end of the treatment. Minocycline will be started at 100 mg once daily and increased to 200 mg at 2 weeks. Celecoxib will be started at 200 mg once daily and increased to 400 mg at 2 weeks. DISCUSSION Anti-inflammatory agents have been shown to be potentially efficacious in the treatment of depressive symptoms. The aim of this study is to determine whether the addition of minocycline and/or celecoxib to TAU improves depressive symptoms in patients with bipolar affective disorder.
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Affiliation(s)
- Muhammad I Husain
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | | | | | - Fareed A Minhas
- Institute of Psychiatry, Rawalpindi Medical College, Rawalpindi
| | - Ajmal Kazmi
- Department of Psychiatry, Karwan-e-Hayat Hospital, Karachi, Pakistan
| | - John Hodsoll
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London
| | - Peter M Haddad
- Division of Psychology and Mental Health, University of Manchester, Manchester
| | - John Fw Deakin
- Division of Psychology and Mental Health, University of Manchester, Manchester
| | - Nusrat Husain
- Division of Psychology and Mental Health, University of Manchester, Manchester
| | - Allan H Young
- Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Safety of research into severe and treatment-resistant mood disorders: analysis of outcome data from 12 years of clinical trials at the US National Institute of Mental Health. Lancet Psychiatry 2016; 3:436-42. [PMID: 26971192 PMCID: PMC4860062 DOI: 10.1016/s2215-0366(16)00006-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/16/2015] [Accepted: 12/21/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Placebo-controlled trials in drug-free patients have long been considered a key research component in the study of mood disorders and relevant treatment mechanisms. However, concerns have been raised about the ethics of such research, leading to an ongoing debate as to whether placebo controls are ethically acceptable. We aimed to assess the cumulative effects of research in individuals with mood disorders and to provide data to address ethical concerns regarding research in this population. METHODS We obtained empirical data for patients screened between between Dec 13, 2001, and Jan 31, 2014, with either major depressive disorder or bipolar disorder who were enrolled in one or more of 18 clinical trials at a US National Institute of Mental Health (NIMH) inpatient or outpatient behavioural health research clinic. We assessed the cumulative effects of research in our patient population, including the effects of drug taper, drug washout, and placebo administration on mood state. Two subgroups were examined: patients enrolled in trials explicitly requiring treatment resistance and patients with a current or past history of suicidal ideation or behaviour. We used the percentage change from screening as the primary outcome measure for statistical analysis of change in mood over study periods. This study is registered with ClinicalTrials.gov, number NCT00024635. FINDINGS We obtained data for 540 patients; 360 (71%) patients were enrolled in trials requiring treatment resistance, 58 (12%) of 465 patients had suicidal ideation at screening, and 191 (60%) of 321 patients had a history of suicidal ideation. Mean mood severity at screening was in the moderate to severe range. Full participation in research, including drug tapers, drug-free periods, and placebo-controlled trials, had a low risk of symptom exacerbation. Patients undergoing drug taper had a mean increase in symptom severity of 4·2% (SD 19·56, tdegrees of freedom 96=1·85; p=0·036). We recorded modest increases in the subgroup who tapered to no medications (mean percentage change 5·1% [SD 18·10], t56=2·12; p=0·039), but increases were not significant in participants enrolled in trials requiring treatment resistance (4·3% [18·60], t72=1·96; p=0·054) and those with a current or past history of suicidal ideation or behaviour (1·8% [18·78], t51=0·68; p=0·50). Six serious adverse events were reported, including one suicide attempt that occurred during the standard treatment phase and not during the clinical trial. INTERPRETATION In general, research participation at the NIMH was not detrimental to health and safety, and conferred benefit in many cases. This finding was true not only in our entire research population, but also in treatment-resistant subgroups and subgroups with a history of suicidality. Our study provides evidence to guide ethical analysis of issues in psychiatric research, and to support continued scientific investigation. FUNDING Intramural Research Program, NIMH, National Institutes of Health.
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Kim SYH, De Vries R, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry 2016; 73:362-8. [PMID: 26864709 PMCID: PMC5530592 DOI: 10.1001/jamapsychiatry.2015.2887] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
IMPORTANCE Euthanasia or assisted suicide (EAS) of psychiatric patients is increasing in some jurisdictions such as Belgium and the Netherlands. However, little is known about the practice, and it remains controversial. OBJECTIVES To describe the characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands. DESIGN, SETTING, AND PARTICIPANTS This investigation reviewed psychiatric EAS case summaries made available online by the Dutch regional euthanasia review committees as of June 1, 2015. Two senior psychiatrists used directed content analysis to review and code the reports. In total, 66 cases from 2011 to 2014 were reviewed. MAIN OUTCOMES AND MEASURES Clinical and social characteristics of patients, physician review process of the patients' requests, and the euthanasia review committees' assessments of the physicians' actions. RESULTS Of the 66 cases reviewed, 70% (n = 46) were women. In total, 32% (n = 21) were 70 years or older, 44% (n = 29) were 50 to 70 years old, and 24% (n = 16) were 30 to 50 years old. Most had chronic, severe conditions, with histories of attempted suicides and psychiatric hospitalizations. Most had personality disorders and were described as socially isolated or lonely. Depressive disorders were the primary psychiatric issue in 55% (n = 36) of cases. Other conditions represented were psychotic, posttraumatic stress or anxiety, somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism. Comorbidities with functional impairments were common. Forty-one percent (n = 27) of physicians performing EAS were psychiatrists. Twenty-seven percent (n = 18) of patients received the procedure from physicians new to them, 14 of whom were physicians from the End-of-Life Clinic, a mobile euthanasia clinic. Consultation with other physicians was extensive, but 11% (n = 7) of cases had no independent psychiatric input, and 24% (n = 16) of cases involved disagreement among consultants. The euthanasia review committees found that one case failed to meet legal due care criteria. CONCLUSIONS AND RELEVANCE Persons receiving EAS for psychiatric disorders in the Netherlands are mostly women and of diverse ages, with complex and chronic psychiatric, medical, and psychosocial histories. The granting of their EAS requests appears to involve considerable physician judgment, usually involving multiple physicians who do not always agree (sometimes without independent psychiatric input), but the euthanasia review committees generally defer to the judgments of the physicians performing the EAS.
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Affiliation(s)
- Scott Y H Kim
- Corresponding author. Department of Bioethics, National Institutes of Health and Adjunct Professor of Psychiatry, University of Michigan. 10 Center Drive, 1C118, Bethesda, MD 20892, USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School; and CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - John R Peteet
- Department of Psychiatry, Brigham and Women’s Hospital and Harvard Medical School
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Long-term morbidity in bipolar-I, bipolar-II, and unipolar major depressive disorders. J Affect Disord 2015; 178:71-8. [PMID: 25797049 DOI: 10.1016/j.jad.2015.02.011] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/09/2015] [Accepted: 02/12/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Long-term symptomatic status in persons with major depressive and bipolar disorders treated clinically is not well established, although mood disorders are leading causes of disability worldwide. AIMS To pool data on long-term morbidity, by type and as a proportion of time-at-risk, based on published studies and previously unreported data. METHODS We carried out systematic, computerized literature searches for information on percentage of time in specific morbid states in persons treated clinically and diagnosed with recurrent major depressive or bipolar I or II disorders, and incorporated new data from one of our centers. RESULTS We analyzed data from 25 samples involving 2479 unipolar depressive and 3936 bipolar disorder subjects (total N=6415) treated clinically for 9.4 years. Proportions of time ill were surprisingly and similarly high across diagnoses: unipolar depressive (46.0%), bipolar I (43.7%), and bipolar II (43.2%) disorders, and morbidity was predominantly depressive: unipolar (100%), bipolar-II (81.2%), bipolar-I (69.6%). Percent-time-ill did not differ between UP and BD subjects, but declined significantly with longer exposure times. CONCLUSIONS The findings indicate that depressive components of all major affective disorders accounted for 86% of the 43-46% of time in affective morbidity that occurred despite availability of effective treatments. These results encourage redoubled efforts to improve treatments for depression and adherence to their long-term use.
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Wooderson SC, Fekadu A, Markopoulou K, Rane LJ, Poon L, Juruena MF, Strawbridge R, Cleare AJ. Long-term symptomatic and functional outcome following an intensive inpatient multidisciplinary intervention for treatment-resistant affective disorders. J Affect Disord 2014; 166:334-42. [PMID: 25012450 DOI: 10.1016/j.jad.2014.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 05/09/2014] [Accepted: 05/10/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The natural history of treatment-resistant depression (TRD) is poor, with high rates of chronicity and recurrence. We describe longer-term symptomatic and functional outcome following multimodal intensive inpatient treatment for TRD. METHODS Symptomatic and functional outcomes were assessed in 71 participants (unipolar, n=51; bipolar, n=20) with severe TRD previously treated at a specialist inpatient unit a median of 34 months (IQR 19-52) post discharge. We looked at outcomes in defined subgroups (unipolar, bipolar and psychotic) and at symptom clusters to see whether certain aspects of depression were more resistant to treatment than others. RESULTS Symptomatic improvement during the admission was maintained at follow up: HDRS21 scores fell from admission (median 22; IQR 19-25) to discharge (median 12; IQR 7-16) and follow-up (median 10; IQR 4-18). Overall, two-thirds of patients were judged to have a good long-term outcome, while half remained in full remission at follow-up. Outcomes were more favourable in bipolar patients, patients without a history of psychosis and patients who were discharged in remission, although a minority of responders at discharge no longer met response criteria at follow up, and conversely some patients discharged as non-responders did subsequently respond. Non-remitting depression was characterised by three main factors; anxiety, cognitive difficulties and sleep disturbance. Those who remitted had better functional outcomes as did those who had experienced a more sustained response to treatment whilst inpatients. Quality of life was poor for those who did not respond to the treatment package. LIMITATIONS Variable follow-up length. CONCLUSIONS This difficult-to-treat population gained long-term benefits from multidisciplinary inpatient treatment. Treatment to remission was associated with more favourable outcomes. Non-responsive depression was characterised by specific symptom clusters that might be amenable to more targeted treatments.
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Affiliation(s)
- Sarah C Wooderson
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
| | - Abebaw Fekadu
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK; Addis Ababa University, College of Health Sciences, Department of Psychiatry, Addis Ababa, Ethiopia
| | - Kalypso Markopoulou
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
| | - Lena J Rane
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
| | - Lucia Poon
- The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
| | - Mario F Juruena
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK; Stress and Affective Disorders (SAD) Programme, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Rebecca Strawbridge
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK
| | - Anthony J Cleare
- King׳s College London, Institute of Psychiatry, Department of Psychological Medicine, Affective Disorders Research Group, 103 Denmark Hill, London SE5 8AZ, UK; The National Affective Disorders Unit, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK; The NIHR Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, King׳s College London, London, UK.
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31
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Abstract
Bipolar disorders of types I and II, even when treated by currently standard options, show a marked excess of depressive morbidity. Treated, type I patients in mid-course or from the onset of illness are ill, overall, 50 % of weeks of follow-up, and 75 % of that unresolved morbidity is depressive. Currently widely held impressions are that bipolar depression typically is poorly responsive to antidepressants, that treatment-resistant depression (TRD) is characteristic of the disorder, and that risk of mania with antidepressant treatment is very high. However, none of these views is supported consistently by available research. TRD may be more prevalent in bipolar than unipolar mood disorders. Relatively intense research attention is directed toward characteristics and treatments of TRD in unipolar depression, but studies of bipolar TRD are uncommon. We found only five controlled trials, plus 10 uncontrolled trials, providing data on a total of 13 drug treatments, all of which involved one or two trials, in 87 % as add-ons to complex, uncontrolled regimens. In two controlled trials, ketamine was superior to placebo but it is short-acting and not orally active; pramipexole was weakly superior to placebo in one controlled trial; three other drugs failed to outperform controls. Other pharmacotherapies are inadequately evaluated and nonpharmacological options are virtually untested in bipolar TRD. The available research supports the view that antidepressants may be effective in bipolar depression provided that currently agitated patients are excluded, that risk of mania with antidepressants is only moderately greater than risk of spontaneous mania, and that bipolar TRD is not necessarily resistant to all treatments.
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