Cognitive control, reward-related decision making and outcomes of late-life depression treated with an antidepressant

Effects of physical activity and depressive symptoms on cognitive function in older adults: National Health and Nutrition Examination Survey

BACKGROUND & AIMS

Population aging is a growing phenomenon, with cognitive impairment becoming a prevalent issue among the elderly. This study aimed to investigate the impact of physical activity and depressive symptoms on cognitive function in older adults using a nationally representative data set of U.S. older adults aged ≥ 60 years.

METHODS

The study comprised 2713 participants aged ≥ 60 from the National Health and Nutrition Examination Survey 2011-2014. Participants were classified into two groups: Cognitive impairment and No-Cognitive impairment, determined by the results of the Digit Symbol Substitution Test (DSST). Physical activity (PA) was assessed using the Global Physical Activity questionnaire (GPAQ), while depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ-9). Logistic regression analysis examined the relationship between physical activity, depressive symptoms and cognitive function.

RESULTS

Multifactorial logistic regression analysis showed that high levels of physical activity were found to be significantly associated with a lower risk of cognitive impairment compared to low levels of physical activity [OR = 0.789, 95% CI:0.632 ~ 0.986, P = 0.037]. On the other hand, the presence of major depressive symptoms was significantly associated with a higher risk of cognitive impairment compared to the absence of depressive symptoms [OR = 3.482, 95% CI: 2.278 ~ 5.324, P < 0.001]. Participants in the recreational physical activity group exhibited higher Cognitive scores (P < 0.001), indicating better cognitive functioning.

CONCLUSION

High levels of Physical activity were independently associated with a lower incident cognitive impairment. Additionally, the severity of depression was positively correlated with an increased risk of cognitive impairment.

Engineering Virtuous health habits using Emotion and Neurocognition: Flexibility for Lifestyle Optimization and Weight management (EVEN FLOW)

Interventions to preserve functional independence in older adults are critically needed to optimize 'successful aging' among the large and increasing population of older adults in the United States. For most aging adults, the management of chronic diseases is the most common and impactful risk factor for loss of functional independence. Chronic disease management inherently involves the learning and adaptation of new behaviors, such as adopting or modifying physical activity habits and managing weight. Despite the importance of chronic disease management in older adults, vanishingly few individuals optimally manage their health behavior in the service of chronic disease stabilization to preserve functional independence. Contemporary conceptual models of chronic disease management and health habit theory suggest that this lack of optimal management may result from an underappreciated distinction within the health behavior literature: the behavioral domains critical for initiation of new behaviors (Initiation Phase) are largely distinct from those that facilitate their maintenance (Maintenance Phase). Psychological factors, particularly experiential acceptance and trait levels of openness are critical to engagement with new health behaviors, willingness to make difficult lifestyle changes, and the ability to tolerate aversive affective responses in the process. Cognitive factors, particularly executive function, are critical to learning new skills, using them effectively across different areas of life and contextual demands, and updating of skills to facilitate behavioral maintenance. Emerging data therefore suggests that individuals with greater executive function are better able to sustain behavior changes, which in turn protects against cognitive decline. In addition, social and structural supports of behavior change serve a critical buffering role across phases of behavior change. The present review attempts to address these gaps by proposing a novel biobehavioral intervention framework that incorporates both individual-level and social support system-level variables for the purpose of treatment tailoring. Our intervention framework triangulates on the central importance of self-regulatory functioning, proposing that both cognitive and psychological mechanisms ultimately influence an individuals' ability to engage in different aspects of self-management (individual level) in the service of maintaining independence. Importantly, the proposed linkages of cognitive and affective functioning align with emerging individual difference frameworks, suggesting that lower levels of cognitive and/or psychological flexibility represent an intermediate phenotype of risk. Individuals exhibiting self-regulatory lapses either due to the inability to regulate their emotional responses or due to the presence of executive functioning impairments are therefore the most likely to require assistance to preserve functional independence. In addition, these vulnerabilities will be more easily observable for individuals requiring greater complexity of self-management behavioral demands (e.g. complexity of medication regimen) and/or with lesser social support. Our proposed framework also intuits several distinct intervention pathways based on the profile of self-regulatory behaviors: we propose that individuals with intact affect regulation and impaired executive function will preferentially respond to 'top-down' training approaches (e.g., strategy and process work). Individuals with intact executive function and impaired affect regulation will respond to 'bottom-up' approaches (e.g., graded exposure). And individuals with impairments in both may require treatments targeting caregiving or structural supports, particularly in the context of elevated behavioral demands.

Sensitivity to intrinsic rewards is domain general and related to mental health

Humans frequently engage in intrinsically rewarding activities (for example, consuming art, reading). Despite such activities seeming diverse, we show that sensitivity to intrinsic rewards is domain general and associated with mental health. In this cross-sectional study, participants online (N = 483) were presented with putative visual, cognitive and social intrinsic rewards as well as monetary rewards and neutral stimuli. All rewards elicited positive feelings (were 'liked'), generated consummatory behaviour (were 'wanted') and increased the likelihood of the action leading to them (were 'reinforcing'). Factor analysis revealed that ~40% of response variance across stimuli was explained by a general sensitivity to all rewards, but not to neutral stimuli. Affective aspects of mental health were associated with sensitivity to intrinsic, but not monetary, rewards. These results may help explain thriving and suffering: individuals with high reward sensitivity will engage in a variety of intrinsically rewarding activities, eventually finding those they excel at, whereas low sensitivity individuals will not.

Course of Subtypes of Late-Life Depression Identified by Bipartite Network Analysis During Psychosocial Interventions

Importance

Approximately half of older adults with depression remain symptomatic at treatment end. Identifying discrete clinical profiles associated with treatment outcomes may guide development of personalized psychosocial interventions.

Objective

To identify clinical subtypes of late-life depression and examine their depression trajectory during psychosocial interventions in older adults with depression.

Design, Setting, and Participants

This prognostic study included older adults aged 60 years or older who had major depression and participated in 1 of 4 randomized clinical trials of psychosocial interventions for late-life depression. Participants were recruited from the community and outpatient services of Weill Cornell Medicine and the University of California, San Francisco, between March 2002 and April 2013. Data were analyzed from February 2019 to February 2023.

Interventions

Participants received 8 to 14 sessions of (1) personalized intervention for patients with major depression and chronic obstructive pulmonary disease, (2) problem-solving therapy, (3) supportive therapy, or (4) active comparison conditions (treatment as usual or case management).

Main Outcomes and Measures

The main outcome was the trajectory of depression severity, assessed using the Hamilton Depression Rating Scale (HAM-D). A data-driven, unsupervised, hierarchical clustering of HAM-D items at baseline was conducted to detect clusters of depressive symptoms. A bipartite network analysis was used to identify clinical subtypes at baseline, accounting for both between- and within-patient variability across domains of psychopathology, social support, cognitive impairment, and disability. The trajectories of depression severity in the identified subtypes were compared using mixed-effects models, and time to remission (HAM-D score ≤10) was compared using survival analysis.

Results

The bipartite network analysis, which included 535 older adults with major depression (mean [SD] age, 72.7 [8.7] years; 70.7% female), identified 3 clinical subtypes: (1) individuals with severe depression and a large social network; (2) older, educated individuals experiencing strong social support and social interactions; and (3) individuals with disability. There was a significant difference in depression trajectories (F2,2976.9 = 9.4; P < .001) and remission rate (log-rank χ22 = 18.2; P < .001) across clinical subtypes. Subtype 2 had the steepest depression trajectory and highest likelihood of remission regardless of the intervention, while subtype 1 had the poorest depression trajectory.

Conclusions and Relevance

In this prognostic study, bipartite network clustering identified 3 subtypes of late-life depression. Knowledge of patients' clinical characteristics may inform treatment selection. Identification of discrete subtypes of late-life depression may stimulate the development of novel, streamlined interventions targeting the clinical vulnerabilities of each subtype.

Reliable Cognitive Decline in Late-Life Major Depression

OBJECTIVE

Major depression in older adults increases the statistical likelihood of dementia. It is challenging to translate statistical evidence of cognitive decline at the group level into knowledge of individual cognitive outcomes. The objective of the current study is to investigate 2-year reliable cognitive change in late-life depression (LLD), which will enhance understanding of cognitive changes in LLD and provide a means to assess individual change.

METHODS

In a sample of non-depressed cognitively normal older adults or NDCN (n = 113), we used linear regression to predict tests of global cognition, processing speed-executive functioning, and memory administered 1 and 2 years later. Stepwise regression was used to select covariates among demographics and raw test scores (either baseline or year 1) and we cross-validated the final models using the predicted residual error sum of squares (PRESS). We then derived a z-change score from the difference between actual and predicted follow-up scores and investigated the proportion of LLD patients (n = 199) and NDCN adults who experienced reliable "decline" (a z-score < -1.645), "stability" (z-scores between + - 1.645), and "improvement" (z scores > +1.645).

RESULTS

A greater proportion LLD compared with NDCN experienced cognitive decline in processing speed/executive functioning and global cognition over 2 years. When compared to NDCN, a greater proportion of LLD also significantly improved on one test of processing speed over 2 years.

CONCLUSIONS

Older adults with LLD are at risk of meaningful cognitive decline over a relatively short period, particularly in the domain of executive functioning and processing speed. This study provides a series of reliable change equations for common neuropsychological tests that can be applied clinically.

[Experience of clinical use of fluvoxamine for the treatment of comorbid depression in childhood and adolescence]

OBJECTIVE

To identify the frequency of administration of fluvoxamine, to determine the main targets of the drug and the expediency of its use in depression of various genesis in children and adolescents.

MATERIAL AND METHODS

To assess the frequency of prescribing fluvoxamine, 195 medical histories of patients who were inpatients in the children's department of the Mental Health Research Center in 2023 were analyzed. To assess the dynamics of depression during treatment with fluvoxamine, a clinical group was formed of 12 patients aged 10 to 15 years (age 13.1±3.6 years) who received fluvoxamine for the treatment of depression with comorbid obsessive-compulsive and anxiety-phobic disorders. Clinical and psychopathological, psychometric (Hamilton Depression Rating Scale - HDRS) and statistical research methods were used.

RESULTS

In total, in 2023, fluvoxamine was received by 20% (n=37) of all inpatient patients of child age (from 7 to 16 years). All patients received combination therapy. The therapeutic targets were comorbid depressive, obsessive-compulsive and anxiety symptoms developing in the structure of nosologically heterogeneous states, with the dominance of schizophrenic spectrum disorders. Against the background of the use of the drug fluvoxamine for 4 weeks in the clinical group, there was a significant reduction in depressive symptoms on the HDRS. Adverse events during complex therapy were observed in 20% of patients, but were not severe, did not require discontinuation of therapy and were unreliably associated with the use of fluvoxamine.

CONCLUSION

The use of the fluvoxamine provides reduction of depressive symptoms within the framework of various nosologies, and is characterized by sufficient safety. The variety of therapeutic targets of the fluvoxamine, including antidepressant, anti-anxiety, cognitive effects, is certainly a significant advantage of the studied fluvoxamine for use in childhood.

Exploration of baseline and early changes in neurocognitive characteristics as predictors of treatment response to bupropion, sertraline, and placebo in the EMBARC clinical trial

BACKGROUND

Treatment for major depressive disorder (MDD) is imprecise and often involves trial-and-error to determine the most effective approach. To facilitate optimal treatment selection and inform timely adjustment, the current study investigated whether neurocognitive variables could predict an antidepressant response in a treatment-specific manner.

METHODS

In the two-stage Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care (EMBARC) trial, outpatients with non-psychotic recurrent MDD were first randomized to an 8-week course of sertraline selective serotonin reuptake inhibitor or placebo. Behavioral measures of reward responsiveness, cognitive control, verbal fluency, psychomotor, and cognitive processing speeds were collected at baseline and week 1. Treatment responders then continued on another 8-week course of the same medication, whereas non-responders to sertraline or placebo were crossed-over under double-blinded conditions to bupropion noradrenaline/dopamine reuptake inhibitor or sertraline, respectively. Hamilton Rating for Depression scores were also assessed at baseline, weeks 8, and 16.

RESULTS

Greater improvements in psychomotor and cognitive processing speeds within the first week, as well as better pretreatment performance in these domains, were specifically associated with higher likelihood of response to placebo. Moreover, better reward responsiveness, poorer cognitive control and greater verbal fluency were associated with greater likelihood of response to bupropion in patients who previously failed to respond to sertraline.

CONCLUSION

These exploratory results warrant further scrutiny, but demonstrate that quick and non-invasive behavioral tests may have substantial clinical value in predicting antidepressant treatment response.

Risk Prediction Models for Depression in Community-Dwelling Older Adults

OBJECTIVE

To develop streamlined Risk Prediction Models (Manto RPMs) for late-life depression.

DESIGN

Prospective study.

SETTING

The Survey of Health, Ageing and Retirement in Europe (SHARE) study.

PARTICIPANTS

Participants were community residing adults aged 55 years or older.

MEASUREMENTS

The outcome was presence of depression at a 2-year follow up evaluation. Risk factors were identified after a literature review of longitudinal studies. Separate RPMs were developed in the 29,116 participants who were not depressed at baseline and in the combined sample of 39,439 of non-depressed and depressed subjects. Models derived from the combined sample were used to develop a web-based risk calculator.

RESULTS

The authors identified 129 predictors of late-life depression after reviewing 227 studies. In non-depressed participants at baseline, the RPMs based on regression and Least Absolute Shrinkage and Selection Operator (LASSO) penalty (34 and 58 predictors, respectively) and the RPM based on Artificial Neural Networks (124 predictors) had a similar performance (AUC: 0.730-0.743). In the combined depressed and non-depressed participants at baseline, the RPM based on neural networks (35 predictors; AUC: 0.807; 95% CI: 0.80-0.82) and the model based on linear regression and LASSO penalty (32 predictors; AUC: 0.81; 95% CI: 0.79-0.82) had satisfactory accuracy.

CONCLUSIONS

The Manto RPMs can identify community-dwelling older individuals at risk for developing depression over 2 years. A web-based calculator based on the streamlined Manto model is freely available at https://manto.unife.it/ for use by individuals, clinicians, and policy makers and may be used to target prevention interventions at the individual and the population levels.

A randomized controlled trial of cognitive control training (CCT) as an add-on treatment for late-life depression: a study protocol

BACKGROUND

Already a major health concern, late-life depression (LLD) is expected to form an increasing problem in the aging population. Moreover, despite current treatments, LLD is associated with a poor long-term prognosis and high rate of chronicity. Treatment provision and treatment accordingly warrant improvement, where add-on treatments might contribute to the efficacy of conventional therapies. Although it is known that impaired cognitive control contributes to LDD, it is not targeted sufficiently by current interventions. Research on cognitive control training (CCT) shows promising results on depressive symptoms, cognitive performance, and overall functioning. However, further research is needed to determine the long-term effects of CCT on LLD, its cost-effectiveness, and mechanisms of change.

METHODS

In the current multicenter randomized controlled trial (RCT) with a between-subjects design participants aged 60 years and over with a current LLD receiving treatment as usual (TAU) are randomized to add-on CCT or placebo training. Randomization is stratified by depression severity. Participants will receive eight online CCT or placebo sessions spread across four consecutive weeks. They will complete a post-training assessment after 1 month and three follow-up assessments scheduled three, six and 12 months after completing the training. We expect CCT and TAU to be more (cost-)effective in reducing depressive symptoms than placebo training and TAU. Additionally, we will be looking at secondary clinical, cognitive and global functioning outcomes and likely mechanisms of change (e.g., improved cognitive functioning, reduced rumination, and improved inhibition of negative stimuli).

DISCUSSION

The proposed RCT aims to contribute to the clinical and scientific knowledge on the long-term effects of CCT as an add-on treatment for LLD. Cost-effectiveness is particularly relevant considering the expected volume of the target demographic. The study will be a pragmatic trial with few inclusion restrictions, providing information on feasibility of web-based trainings in clinical settings. The outcomes are potentially generalizable to guidelines for treatment of LLD.

TRIAL REGISTRATION

This trial is registered in the Netherlands Trial Register (code: NL7639 ). Registered 3 april 2019.

Modifiable predictors of nonresponse to psychotherapies for late-life depression with executive dysfunction: a machine learning approach

The study aimed to: (1) Identify distinct trajectories of change in depressive symptoms by mid-treatment during psychotherapy for late-life depression with executive dysfunction; (2) examine if nonresponse by mid-treatment predicted poor response at treatment end; and (3) identify baseline characteristics predicting an early nonresponse trajectory by mid-treatment. A sample of 221 adults 60 years and older with major depression and executive dysfunction were randomized to 12 weeks of either problem-solving therapy or supportive therapy. We used Latent Growth Mixture Models (LGMM) to detect subgroups with distinct trajectories of change in depression by mid-treatment (6th week). We conducted regression analyses with LGMM subgroups as predictors of response at treatment end. We used random forest machine learning algorithms to identify baseline predictors of LGMM trajectories. We found that ~77.5% of participants had a declining trajectory of depression in weeks 0-6, while the remaining 22.5% had a persisting depression trajectory, with no treatment differences. The LGMM trajectories predicted remission and response at treatment end. A random forests model with high prediction accuracy (80%) showed that the strongest modifiable predictors of the persisting depression trajectory were low perceived social support, followed by high neuroticism, low treatment expectancy, and low perception of the therapist as accepting. Our results suggest that modifiable risk factors of early nonresponse to psychotherapy can be identified at the outset of treatment and addressed with targeted personalized interventions. Therapists may focus on increasing meaningful social interactions, addressing concerns related to treatment benefits, and creating a positive working relationship.

Cognition in Recent Suicide Attempts: Altered Executive Function

Background: Neuropsychological alterations can lead to inaccurate perception, interpretation, and response to environmental information, which could be a risk factor for suicide. Methods: Ninety-six subjects were recruited from the Psychiatry Department of the Araba University Hospital-Santiago, including 20 patients with a recent attempt and diagnosis of major depressive disorder (MDD) according to DSM-V, 33 MDD patients with history of attempted suicide, 23 non-attempter MDD patients, and 20 healthy controls. All participants underwent a clinical interview and neuropsychological assessment on the following cognitive domains: working memory, processing speed, decision-making, executive function, and attention. Backward multiple regressions were performed adjusting for significant confounding variables. For group comparisons, ANOVA and Bonferroni post-hoc tests were performed with a p < 0.05 significance level. Results: The patient groups did not differ regarding severity of depression and stressful events in the last 6 months. In comparison to healthy controls, depressed patients with lifetime suicide attempts had more general trauma (p = 0.003), emotional abuse (p = 0.003), emotional negligence (p = 0.006), and physical negligence (p = 0.009), and depressed patients with recent suicide attempts had experienced more child sexual abuse (p = 0.038). Regarding neuropsychological assessment, all patient groups performed significantly worse than did healthy controls in processing speed, decision-making, and attention. Comparisons between patient groups indicated that recent suicide attempters had poorer performance on executive function in comparison to both depressed lifetime attempters and depressed non-attempters (B = 0.296, p = 0.019, and B = 0.301, p = 0.028, respectively). Besides, women with recent attempts had slightly better scores on executive function than males. Regarding the rest of the cognitive domains, there were no significant differences between groups. Conclusion: Executive function performance is altered in recent suicide attempts. As impaired executive function can be risk factor for suicide, preventive interventions on suicide should focus on its assessment and rehabilitation.

A digital intervention targeting cognitive control network dysfunction in middle age and older adults with major depression

Nonpharmacological interventions targeting putative network mechanisms of major depressive disorder (MDD) may represent novel treatments. This mechanistic study investigates how a video game-like intervention, designed to improve cognitive control network (CCN) functioning by targeting multitasking, influences the CCN of middle-aged and older adults with MDD. The sample consisted of 34 adults aged 45-75 with SCID-defined diagnosis of MDD, Hamilton depression rating scale scores ≥20, and a deficit in cognitive control. Participants were instructed to play at home for 20-25 min per day, at least 5 times per week, for 4 weeks. Evidence of target engagement was defined a priori as >2/3 of participants showing CCN improvement. CCN engagement was defined as a change in a Z score of ≥0.5 on functional magnetic resonance imaging (fMRI) in activation and functional connectivity of the CCN during task-based and resting-state fMRI, respectively. 74% of participants showed a change in activation of the CCN, and 72% showed an increase in resting-state functional connectivity. Sixty-eight percent demonstrated improved cognitive control function, measured as either improvement on sustained attention or working memory performance or reduced self-reported symptoms of apathy on the frontal systems behavioral scale (FrsBe). Participants also reported a significant reduction in mood symptoms measured by PHQ-9. A remotely deployed neuroscience-informed video game-like intervention improves both CCN functions and mood in middle-aged and older adults with MDD. This easily-disseminated intervention may rescue CCN dysfunction present in a substantial subset of middle-aged and older adults with MDD.

Serotonin 2A receptor polymorphism rs3803189 mediated by dynamics of default mode network: a potential biomarker for antidepressant early response

BACKGROUND

Serotonin 2A receptors (HTR2A) play a crucial role in the therapeutic response to antidepressant. The activity of serotonergic system could modulate the connectivity of the default mode network (DMN) in human brain. Our research investigated the influence of the single nucleotide polymorphism (SNP) of HTR2A on the early treatment response of antidepressant and their relation to dynamic changes of DMN for the first time.

METHODS

A total of 134 major depressive disorder patients and 95 healthy controls from two independent datasets were enrolled. All subjects have genotyped candidate HTR2A polymorphisms, dynamic brain parameters flexibility and integration were calculated according to the resting-state functional magnetic resonance imaging (rs-fMRI) at baseline. Patients received selective serotonin reuptake inhibitors (SSRIs) treatment with conventional dose in the next two weeks.

RESULTS

We found the correlation of the risk-associated variant belonged to HTR2A polymorphism rs3803189 with the achievements of antidepressant early response, and also with the stronger dynamic changes of DMN. Further mediation analysis indicated that the bond between rs3803189 and antidepressant early response was mediated by the integration between the right angular gyrus (AG.R) and the subcortical network (SCN), which were validated over both the main and replication datasets.

LIMITATIONS

Except the AG.R-SCN circuit, other factors which influence the relationship between rs3803189 and antidepressant therapy deserve to be explored further. Besides, heterogeneity of samples limited the power of the current result.

CONCLUSIONS

Our findings provided a potential biomarker for individual treatment sensitivity and produced positive effects on revealing the complicated gene-brain-disorder relationship.

Altered cortical morphology in major depression disorder patients with suicidality

Background

Major depressive disorder (MDD) is associated with high risk of suicide, but the biological underpinnings of suicidality in MDD patients are far from conclusive. Previous neuroimaging studies using voxel-based morphometry (VBM) demonstrated that depressed individuals with suicidal thoughts or behaviors exhibit specific cortical structure alterations. To complement VBM findings, surface-based morphometry (SBM) can provide more details into gray matter structure, including the cortical complexity, cortical thickness and sulcal depth for brain images.

Objective

This study aims to use SBM to investigate cortical morphology alterations to obtain evidence for neuroanatomical alterations in depressed patients with suicidality.

Methods

Here, 3D T1-weighted MR images of brain from 39 healthy controls, 40 depressed patients without suicidality (patient controls), and 39 with suicidality (suicidal groups) were analyzed based on SBM to estimate the fractal dimension, gyrification index, sulcal depth, and cortical thickness using the Computational Anatomy Toolbox. Correlation analyses were performed between clinical data and cortical surface measurements from patients.

Results

Surface-based morphometry showed decreased sulcal depth in the parietal, frontal, limbic, occipital and temporal regions and decreased fractal dimension in the frontal regions in depressed patients with suicidality compared to both healthy and patient controls. Additionally, in patients with depression, the sulcal depth of the left caudal anterior cingulate cortex was negatively correlated with Hamilton Depression Rating Scale scores.

Conclusions

Depressed patients with suicidality had abnormal cortical morphology in some brain regions within the default mode network, frontolimbic circuitry and temporal regions. These structural deficits may be associated with the dysfunction of emotional processing and impulsivity control. This study provides insights into the underlying neurobiology of the suicidal brain.

Reward-Processing Behavior in Depressed Participants Relative to Healthy Volunteers: A Systematic Review and Meta-analysis

IMPORTANCE

Dysfunctional reward processing is a leading candidate mechanism for the development of certain depressive symptoms, such as anhedonia. However, to our knowledge, there has not yet been a systematic assessment of whether and to what extent depression is associated with impairments on behavioral reward-processing tasks.

OBJECTIVE

To determine whether depression is associated with impairments in reward-processing behavior.

DATA SOURCES

The MEDLINE/PubMed, Embase, and PsycInfo databases were searched for studies that investigated reward processing using performance on behavioral tasks by individuals with depression and nondepressed control groups, published between January 1, 1946, and August 16, 2019.

STUDY SELECTION

Studies that contained data regarding performance by depressed and healthy control groups on reward-processing tasks were included in the systematic review and meta-analysis.

DATA EXTRACTION AND SYNTHESIS

Summary statistics comparing performance between depressed and healthy groups on reward-processing tasks were converted to standardized mean difference (SMD) scores, from which summary effect sizes for overall impairment in reward processing and 4 subcomponent categories were calculated. Study quality, heterogeneity, replicability-index, and publication bias were also assessed.

MAIN OUTCOME AND MEASURES

Performance on reward-processing tasks.

RESULTS

The final data set comprised 48 case-control studies (1387 healthy control individuals and 1767 individuals with major depressive disorder). The mean age was 37.85 years and 58% of the participants were women. These studies used tasks assessing option valuation (n = 9), reward bias (n = 6), reward response vigor (n = 12), reinforcement learning (n = 20), and grip force (n = 1). Across all tasks, depression was associated with small to medium impairments in reward-processing behavior (SMD = 0.345; 95% CI, 0.209-0.480). When examining reward-processing subcomponent categories, impairment was associated with tasks assessing option valuation (SMD = 0.309; 95% CI, 0.147-0.471), reward bias (SMD = 0.644; 95% CI, 0.270-1.017), and reinforcement learning (SMD = 0.352; 95% CI, 0.115-0.588) but not reward response vigor (SMD = 0.083; 95% CI, -0.144 to 0.309). The medication status of the major depressive disorder sample did not explain any of the variance in the overall effect size. There was significant between-study heterogeneity overall and in all subcomponent categories other than option valuation. Significant publication bias was identified overall and in the reinforcement learning category.

CONCLUSIONS AND RELEVANCE

Relative to healthy control individuals, individuals with depression exhibit reward-processing impairments, particularly for tests of reward bias, option valuation, and reinforcement learning. Understanding the neural mechanisms driving these associations may assist in designing novel interventions.

Treatment Adequacy and Adherence as Predictors of Depression Response in Primary Care

OBJECTIVE

Primary care is the de facto mental health system in the United States where physicians treat large numbers of depressed older adults with antidepressant medication. This study aimed to examine whether antidepressant dosage adequacy and patient adherence are associated with depression response among middle-aged and older adults prescribed with antidepressants by their primary care provider.

DESIGN

A secondary analysis was conducted on a sample drawn from a randomized controlled trial comparing Treatment as Usual to Treatment Initiation Program, an adherence intervention. Treatment Initiation Program improved adherence but not depression compared to Treatment as Usual (Sirey et al., 2017). For this analysis, we examined dosing adequacy and adherence at 6 and 12 weeks as predictors of depression response in both groups at 12 and 24 weeks.

SETTING

Primary care practices.

PARTICIPANTS

One hundred eighty-seven older adults with depression prescribed an antidepressant for depression by their primary care provider.

MEASUREMENTS

Depression response was defined as 50% reduction on the Hamilton Rating Scale for Depression. Adherence was defined as taking 80% of doses at follow-up interviews (6 and 12 weeks). Patient-reported dosage and duration of antidepressant therapy was collected using the Composite Antidepressant Score (adequacy score of >3) at follow-up.

RESULTS

Greater adherence, but not receipt of adequate dosage, was associated with higher likelihood of treatment response at both 12 (Odds ratio (OR) = 2.63; 95% Confidence Interval (CI), 1.19-5.84) and 24 weeks (OR = 3.09; 95% CI, 1.46-6.55).

CONCLUSION

As physicians prescribe antidepressants to the diverse group of adults seen in primary care, special attention to patients' views and approach to adherence may improve depression outcomes.

Pretreatment Reward Sensitivity and Frontostriatal Resting-State Functional Connectivity Are Associated With Response to Bupropion After Sertraline Nonresponse

BACKGROUND

Standard guidelines recommend selective serotonin reuptake inhibitors as first-line antidepressants for adults with major depressive disorder, but success is limited and patients who fail to benefit are often switched to non-selective serotonin reuptake inhibitor agents. This study investigated whether brain- and behavior-based markers of reward processing might be associated with response to bupropion after sertraline nonresponse.

METHODS

In a two-stage, double-blinded clinical trial, 296 participants were randomized to receive 8 weeks of sertraline or placebo in stage 1. Individuals who responded continued on another 8-week course of the same intervention in stage 2, while sertraline and placebo nonresponders crossed over to bupropion and sertraline, respectively. Data from 241 participants were analyzed. The stage 2 sample comprised 87 patients with major depressive disorder who switched medication and 38 healthy control subjects. A total of 116 participants with major depressive disorder treated with sertraline in stage 1 served as an independent replication sample. The probabilistic reward task and resting-state functional magnetic resonance imaging were administered at baseline.

RESULTS

Greater pretreatment reward sensitivity and higher resting-state functional connectivity between bilateral nucleus accumbens and rostral anterior cingulate cortex were associated with positive response to bupropion but not sertraline. Null findings for sertraline were replicated in the stage 1 sample.

CONCLUSIONS

Pretreatment reward sensitivity and frontostriatal connectivity may identify patients likely to benefit from bupropion following selective serotonin reuptake inhibitor failures. Results call for a prospective replication based on these biomarkers to advance clinical care.

Dimensions of Poststroke Depression and Neuropsychological Deficits in Older Adults

OBJECTIVE

Poststroke depression (PSD) has a heterogeneous presentation and is often accompanied by cognitive impairment. This study aimed to identify distinct dimensions of depressive symptoms in older adults with PSD and to evaluate their relationship to cognitive functioning.

DESIGN

Cross-sectional factor and correlational analyses of patients with poststroke depression.

SETTING

Patients were recruited from the community and from acute inpatient stroke rehabilitation hospitals.

PARTICIPANTS

Participants had suffered a stroke and met DSM-IV criteria for major depression (≥18 Montgomery Åsberg Depression Scale; MADRS).

INTERVENTION

None.

MEASUREMENTS

MADRS was used to quantify depression severity at study entry. Neuropsychological assessment at the time of study entry consisted of measures of Global Cognition, Attention, Executive Function, Processing Speed, Immediate Memory, Delayed Memory, and Language.

RESULTS

There were 135 (age ≥50) older adult participants with PSD and varying degrees of cognitive impairment (MMSE Total ≥20). Factor analysis of the MADRS identified three factors, that is sadness, distress, and apathy. Items comprising each factor were totaled and correlated with neuropsychological domain z-score averages. Symptoms of the apathy factor (lassitude, inability to feel) were significantly associated with greater impairment in executive function, memory, and global cognition. Symptoms of the sadness and distress factors had no relationship to cognitive impairment.

CONCLUSION

PSD consists of three correlated dimensions of depressive symptoms. Apathy symptoms are associated with cognitive impairment across several neuropsychological domains. PSD patients with prominent apathy may benefit from careful attention to cognitive functions and by interventions that address both psychopathology and behavioral deficits resulting from cognitive impairment.

Recent advances in the use of imaging in psychiatry: functional magnetic resonance imaging of large-scale brain networks in late-life depression

Advances in neuroimaging have identified neural systems that contribute to clinical symptoms that occur across various psychiatric disorders. This transdiagnostic approach to understanding psychiatric illnesses may serve as a precise guide to identifying disease mechanisms and informing successful treatments. While this work is ongoing across multiple psychiatric disorders, in this article we emphasize recent findings pertaining to major depression in the elderly, or late-life depression (LLD), a common and debilitating neuropsychiatric illness. We discuss how neural functioning of three networks is linked to symptom presentation, illness course, and cognitive decline in LLD. These networks are (1) an executive control network responsible for complex cognitive processing, (2) a default mode network normally deactivated during cognitive demanding when individuals are at rest, and a (3) salience network relevant to attending to internal and external emotional and physiological sensations. We discuss how dysfunction in multiple networks contributes to common behavioral syndromes, and we present an overview of the cognitive control, default mode, and salience networks observed in LLD.

An inverse relationship between cortical plasticity and cognitive inhibition in late-life depression

Executive dysfunction is a common and disabling component of late-life depression (LLD), yet its neural mechanisms remain unclear. In particular, it is not yet known how executive functioning in LLD relates to measures of cortical physiology that may change with age and illness, namely cortical inhibition/excitation and plasticity. Here, we used transcranial magnetic stimulation (TMS) to measure cortical inhibition/excitation (n = 51), and the potentiation of cortical activity following paired associative stimulation, which is thought to reflect long-term potentiation (LTP)-like cortical plasticity (n = 32). We assessed the correlation between these measures of cortical physiology and two measures of executive functioning: cognitive inhibition, assessed using the Delis-Kaplan Executive Function System Color-Word Interference ["Stroop"] Test, and cognitive flexibility, assessed using the Trail Making Test. Correlations with recall memory and processing speed were also performed to assess the specificity of any associations to executive functioning. A significant correlation was found between greater LTP-like cortical plasticity and poorer cognitive inhibition, a core executive function (rp = -0.56, p < 0.001). We did not observe significant associations between cortical inhibition/excitation and executive functioning, or between any neurophysiological measure and cognitive flexibility, memory, or processing speed. Our finding that elevated cortical plasticity is associated with diminished cognitive inhibition emphasizes the importance of balanced synaptic strengthening to healthy cognition. More specifically, our findings suggest that hyper-excitability of cortical circuits following repeated cortical activation may promote inappropriate prepotent responses in LLD. LTP-like cortical plasticity might therefore represent a neural mechanism underlying an inhibitory control cognitive endophenotype of LLD.

Decision Making assessed by the Iowa Gambling Task and Major Depressive Disorder A systematic review

Major Depressive Disorder (MDD) can occur in parallel with cognitive impairment. The search for a neuropsychological profile of depression has been pursued in the last two decades. However, scant research has been done on executive functions and decision-making ability (DM).

[Procognitive effects of fluvoxamine: preliminary data]

AIM

To identify and investigate procognitive effects of fluvoxamine.

MATERIAL AND METHODS

A prospective non-comparative trial of fluvoxamine was carried out in 50 patients in the remission phase of recurrent depressive disorder. To assess the efficacy of therapy, the Stroop color and word test, the Revised version of Addenbrooke's Cognitive Examination, the Frontal Assessment Battery, the Hamilton Depression Scale and the Social Adaptation Self-Evaluation Scale were used. Fluvoxamine was administered at doses of 50-150 mg/day for 24-weeks.

RESULTS

There were the improvement of executive functions, including selective attention and inhibitory control, and recovery of verbal fluency. The procognitive effect of fluvoxamine was dose-dependent and was related to the reduction of residual depressive symptoms.

CONCLUSION

Fluvoxamine has procognitive effects, stabilizes remission and improves social adaptation of the patients.

Advances in Pharmacotherapy of Late-Life Depression

This paper reviews recent research on late-life depression (LLD) pharmacotherapy, focusing on updated information for monotherapy and augmentation treatments. We then review new research on moderators of clinical response and how to use the information for improved efficacy.

RECENT FINDINGS

A recent review shows that sertraline, paroxetine, and duloxetine were superior to placebo for the treatment of LLD. There is concern that paroxetine could have adverse outcomes in the geriatric population due to anticholinergic properties; however, studies show no increases in mortality, dementia risk, or cognitive measures. Among newer antidepressants, vortioxetine has demonstrated efficacy in LLD, quetiapine has demonstrated efficacy especially for patients with sleep disturbances, and aripiprazole augmentation for treatment resistance in LLD was found to be safe and effective. Researchers have also been identifying moderators of LLD that can guide treatment. Researchers are learning how to associate moderators, neuroanatomical models, and antidepressant response. SSRI/SNRIs remain first-line treatment for LLD. Aripiprazole is an effective and safe augmentation for treatment resistance. Studies are identifying actionable moderators that can increase treatment response.

State of the Science of Neural Systems in Late-Life Depression: Impact on Clinical Presentation and Treatment Outcome

Major depression in older adults, or late-life depression (LLD), is a common and debilitating psychiatric disorder that increases the risk of morbidity and mortality. Although the effects of LLD make it important to achieve a diagnosis and start treatment quickly, individuals with LLD are often inadequately or unsuccessfully treated. The latest treatment developments suggest that interventions targeting executive dysfunction and neuroticism, constructs associated with poor response to antidepressants in older adults, are successful in treating LLD. Specific behavioral interventions (computerized cognitive training, mindfulness meditation, aerobic exercise) appear to decrease depressive symptoms and ameliorate executive dysfunction and neuroticism, but we do not fully understand the mechanisms by which these treatments work. We review recent research on neural network changes underlying executive dysfunction and neuroticism in LLD and their association with clinical outcomes (e.g., treatment response, cognitive functioning).

Training Rehabilitation as an Effective Treatment for Patients With Vascular Cognitive Impairment With No Dementia

PURPOSE

The aim of this study was to investigate the possible therapeutic effect of cognitive training on the cognitive function of patients with vascular cognitive impairment with no dementia (VCIND).

DESIGN

A randomized controlled trial.

METHOD

Seventy-three cases of VCIND patients were used as subjects, of which 36 patients were subjected to routine care with systemic cognitive training and classified as the intervention group, whereas the other 37 patients were subjected to a routine care only and classified as the control group. Multidimensional neuropsychological assessments were performed 3 months before and after the intervention.

FINDINGS

The patients' performance on functional tests was significantly improved after intervention (p < .05) except from Stroop Color-Word Test (p ≥ .05).

CONCLUSIONS

After systemic cognitive training, VCIND patients showed a significant improvement in visuospatial function, memory function, language function, and attention function, whereas their execution function was partially improved.

CLINICAL RELEVANCE

Despite the promising results, there is still a need to improve the support for patients affected by VCIND requiring rehabilitation.

A Systematic Review of Cognitive Predictors of Treatment Outcome in Major Depression

Background: Research suggests that only 50% of patients with major depression respond to psychotherapy or pharmacological treatment, and relapse is common. Therefore, there is interest in elucidating factors that help predict clinical response. Cognitive impairment is a key feature of depression, which often persists beyond remission; thus, the aim of this systematic review was to determine whether baseline cognitive functioning can predict treatment outcomes in individuals with depression. Method: Studies examining cognitive predictors of treatment response in depression were identified using Pub Med and Web of Science databases. Given the heterogeneity of outcome measures, the variety of treatment protocols, and the differing ways in which data was presented and analyzed, a narrative rather than meta-analytic review technique was used. Results: 39 studies met inclusion criteria. Findings in younger adult samples were inconclusive. There was some evidence for a predictive effect of executive function and to a lesser extent, psychomotor speed, on treatment response. There was no evidence of learning or memory being associated with treatment response. In older-aged samples, the evidence was much more consistent, suggesting that poor executive function predicts poor response to SSRIs. Conclusions: Findings from the present review suggest that certain aspects of cognitive functioning, particularly executive function, may be useful in predicting treatment response in depression. This is certainly the case in elderly samples, with evidence suggesting that poor executive functioning predicts poor response to SSRIs. With further research, baseline cognitive functioning may serve as a factor which helps guide clinical decision making. Moreover, cognitive deficits may become targets for specific pharmacological or psychological treatments, with the hope of improving overall outcome.

Meta-Analytic Evidence for a Reversal Learning Effect on the Iowa Gambling Task in Older Adults

Iowa Gambling Task (IGT) is one of the most widely used tools to assess economic decision-making. However, the research tradition on aging and the Iowa Gambling Task (IGT) has been mainly focused on the overall performance of older adults in relation to younger or clinical groups, remaining unclear whether older adults are capable of learning along the task. We conducted a meta-analysis to examine older adults' decision-making on the IGT, to test the effects of aging on reversal learning (45 studies) and to provide normative data on total and block net scores (55 studies). From the accumulated empirical evidence, we found an average total net score of 7.55 (±25.9). We also observed a significant reversal learning effect along the blocks of the IGT, indicating that older adults inhibit the prepotent response toward immediately attractive options associated with high losses, in favor of initially less attractive options associated with long-run profit. During block 1, decisions of older adults led to a negative gambling net score, reflecting the expected initial pattern of risk-taking. However, the shift toward more safe options occurred between block 2 (small-to-medium effect size) and blocks 3, 4, 5 (medium-to-large effect size). These main findings highlight that older adults are able to move from the initial uncertainty, when the possible outcomes are unknown, to decisions based on risk, when the outcomes are learned and may be used to guide future adaptive decision-making.

Improving late life depression and cognitive control through the use of therapeutic video game technology: A proof-of-concept randomized trial

BACKGROUND

Existing treatments for depression are known to have only modest effects, are insufficiently targeted, and are inconsistently utilized, particularly in older adults. Indeed, older adults with impaired cognitive control networks tend to demonstrate poor response to a majority of existing depression interventions. Cognitive control interventions delivered using entertainment software have the potential to not only target the underlying cerebral dysfunction associated with depression, but to do so in a manner that is engaging and engenders adherence to treatment protocol.

METHODS

In this proof-of-concept trial (Clinicaltrials.gov #: NCT02229188), individuals with late life depression (LLD) (22; 60+ years old) were randomized to either problem solving therapy (PST, n = 10) or a neurobiologically inspired digital platform designed to enhance cognitive control faculties (Project: EVO™, n = 12). Given the overlapping functional neuroanatomy of mood disturbances and executive dysfunction, we explored the impact of an intervention targeting cognitive control abilities, functional disability, and mood in older adults suffering from LLD, and how those outcomes compare to a therapeutic gold standard.

RESULTS

EVO participants demonstrated similar improvements in mood and self-reported function after 4 weeks of treatment to PST participants. The EVO participants also showed generalization to untrained measures of working memory and attention, as well as negativity bias, a finding not evident in the PST condition. Individuals assigned to EVO demonstrated 100% adherence.

CONCLUSIONS

This study provides preliminary findings that this therapeutic video game targeting cognitive control deficits may be an efficacious LLD intervention. Future research is needed to confirm these findings.

Neuroticism Traits Selectively Impact Long Term Illness Course and Cognitive Decline in Late-Life Depression

OBJECTIVES

Neuroticism is a broad construct that conveys a predisposition to experience psychological distress and negative mood states. Vulnerability to stress (VS) is one neuroticism trait that has been linked to worse mood and cognitive outcomes in older adults. We hypothesized that elevated VS would be associated with worse illness course and cognitive decline in older adults with late-life major depression (LLD).

DESIGN

Participants were enrolled in the Neurocognitive Outcomes of Depression in the Elderly (NCODE), a longitudinal investigation of the predictors of poor illness course and cognitive decline in LLD. Participants were followed upwards of 10 years.

SETTING

NCODE operates in a naturalistic treatment milieu.

PARTICIPANTS

112 participants aged 60 and older with a current diagnosis of major depressive disorder.

MEASUREMENTS

Treatment response was assessed at least every 3 months and more often if clinically needed. Participants also completed the NEO Personality Inventory-Revised (NEO PI-R) and an annual cognitive examination. Neuroticism traits from the NEO PI-R included anxiety, depression, anger-hostility, self-consciousness, impulsivity, and VS.

RESULTS

Higher neuroticism traits of VS, impulsivity, anger-hostility, and anxiety were associated with worse treatment response over time. High VS was the only neuroticism trait significantly associated with cognitive functioning. High VS negatively influenced the rate of global cognitive decline over time.

CONCLUSIONS

Individual personality traits within the neuroticism dimension are associated with treatment resistance and cognitive impairment in LLD. It remains to be seen whether these individual traits are associated with different neurobiological substrates and clinical characteristics of LLD.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.