Heterogeneity in the prognosis of major depression: from the common cold to a highly debilitating and recurrent illness

Identifying active ingredients in cognitive-behavioral therapies: What if we didn't?

Identifying active ingredients of psychological interventions is a major goal of psychotherapy researchers that is often justified by the promise that it will lead to improved patient outcomes. Much of this "active ingredients" research is conducted within randomized controlled trials (RCTs) with patient populations, putting it in Phase T2 of the clinical-translational spectrum. I argue that RCTs in patient populations are very "messy laboratories" in which to conduct active ingredient work and that T0 and T1 research provide more controlled contexts. However, I call attention to the long road from identifying active ingredients of CBTs, whether in T0, T1, or T2 research, to improving outcomes. Dissemination and implementation research (T3 and T4 approaches) may be conceptually closer to improving outcomes. Given how common and disabling mental health symptoms are, I argue that if researchers want to improve patient outcomes, these research programs must receive more attention including work on the uptake of psychological interventions as well as work on optimal ordering of existing interventions.

Association between decreased interhemispheric functional connectivity of the insula and duration of illness in recurrent depression

OBJECTIVE

To investigate the altered interhemispheric functional connectivity in the resting state in patients with recurrent major depressive disorder (MDD).

METHODS

Voxel-mirrored homotopic connectivity (VMHC), a measure of the functional connectivity between any pair of symmetrical interhemispheric voxels, and pattern classification were examined in 41 recurrent MDD patients (22 during the depressive state and 19 during the remitted state) and 60 age, sex, and education level-matched healthy controls (HC) using resting-state functional magnetic resonance imaging (fMRI).

RESULTS

Compared with HC, the recurrent MDD patients exhibited decreased VMHC values in the bilateral fusiform, inferior occipital gyrus, posterior insula, precentral gyrus, precuneus, superior temporal gyrus, and thalamus. A significant negative correlation between the VMHC value of the bilateral posterior insula and illness duration in recurrent MDD was identified. Support vector machine (SVM) analysis showed that VMHC in the fusiform and posterior insula could be used to distinguish recurrent MDD patients from HC with a sensitivity and accuracy >0.6.

CONCLUSION

Our findings revealed a reduction in the resting-state brain activity across several neural networks in patients with recurrent MDD, including within the posterior insula. Lower VMHC values in the posterior insula were associated with longer illness duration, suggesting that impairment in interhemispheric synchronization within the salience network may be due to the accumulated pathology of depression and may contribute to future depression relapse. VMHC changes in the posterior insula may serve as a potential imaging marker to discriminate recurrent MDD patients from HC.

Stratification of individuals with lifetime depression and low wellbeing in the UK Biobank

BACKGROUND

Previous studies stratified patients with major depressive disorder (MDD) based on their clinical characteristics. This study used this approach in individuals with lifetime MDD who reported low wellbeing, a group of high clinical relevance.

METHODS

We selected participants in the UK Biobank (UKB) with lifetime MDD and a wellbeing score in the lowest 25 %. A wellbeing score was previously created considering happiness, belief that own life is meaningful, health satisfaction and functioning in relevant areas. In the selected group, we applied latent class analysis using mood-spectrum symptoms and personality traits as input variables, then we compared the clinical-demographic and genetic (polygenic risk scores, PRSs) characteristics of the identified classes.

RESULTS

A total of 13,896 individuals were included and a model with five classes showed the best performance. The most common class (31.25 %) was characterised by periods of irritable mood and trait irritability with high neuroticism. A rarer class (16.49 %) showed depressive-manic mood fluctuations and risk-taking personality, higher percentage of males, atypical depressive symptoms, lower socio-economic status, higher PRS for attention-deficit hyperactivity disorder and lower PRS for education. The second most common class (29.79 %) showed worry as main personality trait with low risk of manic/irritable manifestations. The remaining classes showed an anxious-irritable personality profile and a purely depressive profile (4.92 % and 17.55 %, respectively).

LIMITATIONS

Our results may reflect the characteristics of UKB participants.

CONCLUSIONS

Subthreshold manic/irritable mood fluctuations and personality traits irritability and neuroticism may distinguish the most common groups with poor wellbeing in lifetime MDD.

Do Sleep Disturbances Improve Following Psychoanalytic Psychotherapy for Adolescent Depression?

Sleep disturbance is often a prominent symptom in adolescents diagnosed with major depressive disorder (MDD). Recent evidence indicates that short-term psychoanalytic psychotherapy (STPP) for depression may have an effect in reducing co-occurring sleep disturbance in youth. It is unknown if transference work (exploration of the patient–therapist relationship) has an additional effect in reducing sleep disturbance. Adolescents aged 16–18 years (n = 69, 84% female) who met diagnostic criteria for MDD based on the Mini International Neuropsychiatric Interview (M.I.N.I) were randomized to either STPP with transference work or without. Sleep problems were assessed at baseline, therapy session 20 (20 weeks), post-treatment (28 weeks), and one-year follow-up (80 weeks) with the Symptom Checklist-90-R. At baseline, 69% of the adolescents exhibited moderately to extreme sleep difficulties. Sleep disturbance was significantly correlated to depression depth at session 20 and at follow-up. Symptoms of insomnia significantly decreased from baseline to the end of treatment. Treatment gains were maintained until follow-up. No differences in recovery of sleep disturbance were found between the two treatment groups. The findings suggest that sleep disturbance improves following STPP for depression, with or without transference work. Future research should assess those with residual symptoms by different sleep measures.

Mapping network connectivity between internet addiction and residual depressive symptoms in patients with depression

BACKGROUND AND AIMS

Depression often triggers addictive behaviors such as Internet addiction. In this network analysis study, we assessed the association between Internet addiction and residual depressive symptoms in patients suffering from clinically stable recurrent depressive disorder (depression hereafter).

MATERIALS AND METHODS

In total, 1,267 depressed patients were included. Internet addiction and residual depressive symptoms were measured using the Internet Addiction Test (IAT) and the two-item Patient Health Questionnaire (PHQ-2), respectively. Central symptoms and bridge symptoms were identified via centrality indices. Network stability was examined using the case-dropping procedure.

RESULTS

The prevalence of IA within this sample was 27.2% (95% CI: 24.7-29.6%) based on the IAT cutoff of 50. IAT15 ("Preoccupation with the Internet"), IAT13 ("Snap or act annoyed if bothered without being online") and IAT2 ("Neglect chores to spend more time online") were the most central nodes in the network model. Additionally, bridge symptoms included the node PHQ1 ("Anhedonia"), followed by PHQ2 ("Sad mood") and IAT3 ("Prefer the excitement online to the time with others"). There was no gender difference in the network structure.

CONCLUSION

Both key central and bridge symptoms found in the network analysis could be potentially targeted in prevention and treatment for depressed patients with comorbid Internet addiction and residual depressive symptoms.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Assessing the disproportionality of depressive reactions to life stress

BACKGROUND

Prior to DSM-5, depression had long been conceptualized as symptoms without cause or disproportionate to one's circumstances. A central challenge to considering whether a depressive reaction is disproportionate is the lack of measures assessing disproportionality. Drawing on a study of patients participating in cognitive behavioural therapy for depression, we evaluate two new measures of the disproportionality of one's depressive symptoms to their recent life circumstances.

METHODS

To assess the disproportionality of depressive symptoms, we developed an interview-based assessment and a brief self-report measure. We employed both assessments in a sample of 126 patients who participated in cognitive behavioural therapy for depression.

RESULTS

Initial evidence for the reliability and validity of both self-report and interview-based approaches appeared promising. Interview judges demonstrated strong inter-rater reliability on life stress ratings, and both forms of disproportionality showed a pattern of correlations with variables reflecting greater clinical complexity, including self-reported personality dysfunction and symptom severity. Comorbid generalized anxiety disorder (GAD) was the only previously proposed marker of complicated depression to significantly predict both disproportionality scores.

LIMITATIONS

The sample had limited ethnic diversity and tended to be highly educated. Participants all met criteria for major depressive disorder and sought treatment.

CONCLUSIONS

Two assessments of the disproportionality of depressive reactions demonstrated evidence of reliability and validity. Despite limited efforts at assessment to date, these results suggest these measures may be able to reliably distinguish the disproportionality of depressive reactions and allow clinicians to better assess contextual life stress depressive disorders.

Prevalence of suicidal ideation and planning in patients with major depressive disorder: A meta-analysis of observation studies

BACKGROUND

Suicidal ideation (SI) and suicide planning (SP) are associated with an increased risk of future suicide. We performed a meta-analysis of observational studies to estimate the prevalence of SI and SP in patients with major depressive disorder (MDD) and its associated factors.

METHODS

A systematic literature search was conducted in PubMed, EMBASE, PsycINFO and Web of Science from their commencement date until 7 October 2020. Original studies containing data on the prevalence of SI and SP in individuals with MDD were analyzed.

RESULTS

Forty-six articles covering 53,598 patients were included in the meta-analysis. The overall prevalence of SI was 37.7% (95% confidence interval (CI): 32.3-43.4%) and the pooled prevalence of SP was 15.1% (95% CI: 8.0--26.8%). Subgroup analyses revealed that the timeframe over which SI was assessed, source of patients, study design, and diagnostic criteria were significantly associated with the pooled prevalence of SI. Meta-regression analyses revealed that the Hamilton Depression Rating Scale (HAMD) score and percentage of male participants were positively associated with the pooled prevalence of SI. Study quality and mean age were negatively associated with the pooled prevalence of SI. In contrast, survey year and study quality were negatively associated with pooled prevalence of SP LIMITATION: SI and SP were self-reported and subject to recall bias and impression management.

CONCLUSIONS

SI and SP are common in patients with MDD, especially among inpatients. Preventive measures and treatments focusing on factors associated with SI and SP may reduce the risk of suicide in patients with MDD.

Heterogeneity in major depression and its melancholic and atypical specifiers: a secondary analysis of STAR*D

OBJECTIVES

The melancholic and atypical specifiers for a major depressive episode (MDE) are supposed to reduce heterogeneity in symptom presentation by requiring additional, specific features. Fried et al. (2020) recently showed that the melancholic specifier may increase the potential heterogeneity in presenting symptoms. In a large sample of outpatients with depression, our objective was to explore whether the melancholic and atypical specifiers reduced observed heterogeneity in symptoms.

METHODS

We used baseline data from the Inventory of Depression Symptoms (IDS), which was available for 3,717 patients, from the Sequenced Alternatives to Relieve Depression (STAR*D) trial. A subsample met criteria for MDE on the IDS ("IDS-MDE"; N =2,496). For patients with IDS-MDE, we differentiated between those with melancholic, non-melancholic, non-melancholic, atypical, and non-atypical depression. We quantified the observed heterogeneity between groups by counting the number of unique symptom combinations pertaining to their given diagnostic group (e.g., counting the melancholic symptoms for melancholic and non-melancholic groups), as well as the profiles of DSM-MDE symptoms (i.e., ignoring the specifier symptoms).

RESULTS

When considering the specifier and depressive symptoms, there was more observed heterogeneity within the melancholic and atypical subgroups than in the IDS-MDE sample (i.e., ignoring the specifier subgroups). The differences in number of profiles between the melancholic and non-melancholic groups were not statistically significant, irrespective of whether focusing on the specifier symptoms or only the DSM-MDE symptoms. The differences between the atypical and non-atypical subgroups were smaller than what would be expected by chance. We found no evidence that the specifier groups reduce heterogeneity, as can be quantified by unique symptom profiles. Most symptom profiles, even in the specifier subgroups, had five or fewer individuals.

CONCLUSION

We found no evidence that the atypical and melancholic specifiers create more symptomatically homogeneous groups. Indeed, the melancholic and atypical specifiers introduce heterogeneity by adding symptoms to the DSM diagnosis of MDE.

Socioeconomic inequalities in impairment associated with depressive symptoms: Evidence from the National Survey on Drug Use and Health

OBJECTIVE

Individuals with low socioeconomic status have higher rates of depression, but it is unknown whether the socioeconomically disadvantaged also have more disabling depressive symptoms. We examined (1) the associations of three indicators of socioeconomic status with depression-related severe role impairment, and (2) whether socioeconomic factors moderate the association between individual depression symptoms and depression-related severe role impairment.

METHODS

We used data from the National Survey on Drug Use and Health (NSDUH). Depressive symptoms, role impairment and socioeconomic indicators (poverty, participation in workforce, educational attainment) were self-reported by participants. The analytic sample consisted of participants who screened positive for a depressive episode during past 12 months (n = 32 661). We used survey-weighted logistic models to examine the associations of depressive symptoms with severe role impairment and the modifying effects of socioeconomic indicators.

RESULTS

The association between depression symptom count and severe role impairment was stronger among those not in workforce (OR = 1.12[1.02-1.23]). The association between specific depression symptoms and severe role impairment was stronger for conditions of poverty (fatigue, OR = 2.97 [1.54-5.73]; and anhedonia, OR = 1.93[1.13-3.30]), workforce non-participation (inability to concentrate/indecisiveness, OR = 1.54[1.12-2.12]), and lower educational attainment (anhedonia, OR = 0.77 [0.59-0.99]). Feelings of worthlessness was the only symptom with independent associations for all socioeconomic groups (adjusted OR = 1.91[1.35-2.70]).

CONCLUSION

Depression was more frequent and also more disabling for socioeconomically disadvantaged groups, especially when assessed with workforce participation. Additionally, some specific symptoms showed socioeconomic differences. Our findings highlight the need to prioritize population groups with more severe impairment associated with depressive symptoms.

Optimal well-being in the aftermath of anxiety disorders: A 10-year longitudinal investigation

BACKGROUND

Although preliminary research has explored the possibility of optimal well-being after depression, it is unclear how rates compare to anxiety. Using Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) as exemplars of anxiety, we tested the rates of optimal well-being one decade after being diagnosed with an anxiety disorder. Based on reward deficits in depression, we pre-registered our primary hypothesis that optimal well-being would be more prevalent after anxiety than depression as well as tested two exploratory hypotheses.

METHOD

We used data from the Midlife in the United States (MIDUS) study, which contains a nationally representative sample across two waves, 10 years apart. To reach optimal well-being, participants needed to have no symptoms of GAD, PD, or major depressive disorder (MDD) at the 10 year follow-up and exceed cut-offs across nine dimensions of well-being.

RESULTS

The results failed to support our primary hypothesis. Follow-up optimal well-being rates were highest for adults previously diagnosed with MDD (8.7%), then PD (6.1%), and finally GAD (0%). Exploratory analyses revealed optimal well-being was approximately twice as prevalent in people without anxiety or depression at baseline and provided partial support for baseline well-being predicting optimal well-being after anxiety. Results were largely replicated across different classifications of optimal well-being.

LIMITATIONS

Findings are limited by the somewhat unique measurement of anxiety in the MIDUS sample as well as the relatively high rate of missing data.

CONCLUSIONS

We discuss possible explanations for less prevalent optimal well-being after anxiety vs. depression and the long-term positivity deficits from GAD.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

The significance of anxiety symptoms in predicting psychosocial functioning across borderline personality traits

Emotion regulation is a central task of daily life. Difficulty regulating emotions is a core feature of borderline personality disorder (BPD), one of the most common and impairing personality disorder diagnoses. While anger and symptoms of depression are instantiated in the criteria for BPD, anxiety is not, despite being among the most common psychiatric symptoms. In a sample of online respondents (N = 471), we explored the interactions between anxiety symptoms and BPD traits in predicting well-being (WHO-5) as well as poorer work and social adjustment (WSAS), while controlling for anger and depression. We hypothesized that anxiety would lead to more impairment (i.e., lower well-being and poorer work and more difficulties with work and social adjustment) as BPD traits increased. BPD traits and symptoms of anxiety both contributed to overall lower levels well-being and higher levels of psychosocial dysfunction. However, contrary to our expectations, at higher (vs. lower) levels of BPD traits, symptoms of anxiety were less conducive to lower well-being on the WHO-5. For the WSAS, there was no consistent evidence for an interaction between BPD traits and anxiety in predicting functioning. By and large, our results do not support the idea that anxiety contributes to more impairment at higher levels of BPD traits.

Individual Differences in the Stability and Change of Childhood Depression: A Growth Mixture Model With Structured Residuals

Studies of developmental trajectories of depression are important for understanding depression etiology. Existing studies have been limited by short time frames and no studies have explored a key factor: differential patterns of responding to life events. This article introduces a novel analytic technique, growth mixture modeling with structured residuals, to examine the course of youth depression in a large, prospective cohort (N = 11,641, ages 4-16.5, 96% White). Age-specific critical points were identified at ages 8 and 13 where depression symptoms spiked for a minority of children. Most depression risk was due to dynamic responses to environmental events, drawn not from a small pool of persistently depressed children, but a larger pool of children who varied across higher and lower symptom levels.

Carving depression at its joints? Psychometric properties of the Sydney Melancholia Prototype Index

Parker and colleagues developed the Sydney Melancholia Prototype Index (SMPI), a 24-item measure to assess a potential subtype of depression: melancholia. While research supports the validity of the measure, no study has assessed its psychometric properties. We recruited 1633 participants online, of whom 487 reported a lifetime period of depressed mood or anhedonia and were administered the SMPI. We conducted confirmatory factor analyses (CFA) of the SMPI, to assess the proposed fit of the measure. We also conducted exploratory factor analyses (EFA) to explore the structure implied by the current data. CFA did not support the hypothesized factor structure of the SMPI, no matter what structure we assumed as primary (i.e., a one factor, two factor, or bifactor model). An EFA suggested a five-factor solution wherein several items did not appear to co-vary reliably and other factors captured the severity of melancholic symptoms, negative mood reactivity, positive mood reactivity, emotionality and family relationships, and early life adversity. The SMPI may not measure a single construct. Future research should explore the longitudinal association between depression severity, contaminant symptoms, positive and negative mood reactivity, and early life experiences.

Double trouble: Do symptom severity and duration interact to predicting treatment outcomes in adolescent depression?

Studies suggest that depression severity and duration interact to predict outcomes in depression treatment. To our knowledge, no study has explored this question in a sample with a placebo control, two therapies, and their combination nor with adolescents. We used data from the Treatment of Adolescent Depression Study (N=439), in which adolescent were randomized to placebo (PBO), cognitive-behavioral therapy (CBT), antidepressants medications (MEDs), or their combination (COMB). We explore the interaction between depression severity, chronicity, and treatments (vs. placebo) in predicting outcomes. There was interaction between severity and chronicity when comparing COMB and CBT with PBO, but not MEDs. In non-chronic depression, the effects of CBT were inversely related to severity to the point that CBT appeared iatrogenic with more severe depression. In chronic depression, the effects of CBT did not vary by severity, but the relative effects of COMB grew, being smallest in milder, more dysthymic-like depression, and largest in chronic-severe depression. These findings support calls to classify depression by severity and chronicity as well efforts to risk stratify patients to different intensity of care according to these variables.

Predicting optimal interventions for clinical depression: Moderators of outcomes in a positive psychological intervention vs. cognitive-behavioral therapy

Identifying differences in the clinical response to specific interventions is an important challenge in the field of Clinical Psychology. This is especially true in the treatment of depression where many treatments appear to have comparable outcomes. In a controlled trial, we compared a positive psychology group intervention, the Integrative Positive Psychological Intervention for Depression (IPPI-D; n = 62) to a cognitive-behavioral therapy group intervention (CBT; n = 66) for depression. No statistically or clinically-significant differences between the treatments were found, but a slight advantage was observed, on average, for IPPI-D. The aim of the present study was to identify and combine moderators of the differential efficacy of these two psychological interventions for clinical depression. For this purpose, a secondary analysis using the Personalized Advantage Index (PAI) was performed to identify the intervention predicted to produce the better outcome for each patient. Six of the 21 potential moderators were found to predict differential efficacy between the treatments. IPPI-D was predicted to be the optimal treatment for 73% of the sample. Baseline features that characterized these individuals were: mental and physical comorbidity, prior antidepressant medication, higher levels of negative thoughts, and higher personal growth. The 27% who were predicted to achieve better outcomes in CBT than in IPPI-D tended to have these baseline features: no comorbidities, no prior antidepressant medication, lower levels of negative thoughts, and lower personal growth.

A prognostic index for long-term outcome after successful acute phase cognitive therapy and interpersonal psychotherapy for major depressive disorder

BACKGROUND

Major depressive disorder (MDD) has a highly recurrent nature. After successful treatment, it is important to identify individuals who are at risk of an unfavorable long-term course. Despite extensive research, there is no consensus yet on the clinically relevant predictors of long-term outcome in MDD, and no prediction models are implemented in clinical practice. The aim of this study was to create a prognostic index (PI) to estimate long-term depression severity after successful and high quality acute treatment for MDD.

METHODS

Data come from responders to cognitive therapy (CT) and interpersonal psychotherapy (IPT) in a randomized clinical trial (n = 85; CT = 45, IPT = 40). Primary outcome was depression severity, assessed with the Beck Depression Inventory II, measured throughout a 17-month follow-up phase. We examined 29 variables as potential predictors, using a model-based recursive partitioning method and bootstrap resampling in conjunction with backwards elimination. The selected predictors were combined into a PI. Individual PI scores were estimated using a cross-validation approach.

RESULTS

A total of three post-treatment predictors were identified: depression severity, hopelessness, and self-esteem. Cross-validated PI scores evidenced a strong correlation (r = 0.60) with follow-up depression severity.

CONCLUSION

Long-term predictions of MDD are multifactorial, involving a combination of variables that each has a small prognostic effect. If replicated and validated, the PI can be implemented to predict follow-up depression severity for each individual after acute treatment response, and to personalize long-term treatment strategies.

The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis

Background

Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT.

Objective

We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria’s effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes.

Methods

We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review.

Results

Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes.

Conclusions

A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies.

Risk factors for relapse and recurrence of depression in adults and how they operate: A four-phase systematic review and meta-synthesis

PURPOSE

To review and synthesise prognostic indices that predict subsequent risk, prescriptive indices that moderate treatment response, and mechanisms that underlie each with respect to relapse and recurrence of depression in adults.

RESULTS AND CONCLUSIONS

Childhood maltreatment, post-treatment residual symptoms, and a history of recurrence emerged as strong prognostic indicators of risk and each could be used prescriptively to indicate who benefits most from continued or prophylactic treatment. Targeting prognostic indices or their "down-stream" consequences will be particularly beneficial because each is either a cause or a consequence of the causal mechanisms underlying risk of recurrence. The cognitive and neural mechanisms that underlie the prognostic indices are likely addressed by the effects of treatments that are moderated by the prescriptive factors. For example, psychosocial interventions that target the consequences of childhood maltreatment, extending pharmacotherapy or adapting psychological therapies to deal with residual symptoms, or using cognitive or mindfulness-based therapies for those with prior histories of recurrence. Future research that focuses on understanding causal pathways that link childhood maltreatment, or cognitive diatheses, to dysfunction in the neocortical and limbic pathways that process affective information and facilitate cognitive control, might result in more enduring effects of treatments for depression.

Are studies of psychotherapies for depression more or less generalizable than studies of antidepressants?

BACKGROUND

The generalizability of findings from studies exploring the efficacy of psychotherapy and antidepressants has been called into question in part because studies exclude many patients. Despite this, the frequency with which psychotherapy and antidepressant studies use specific inclusion and exclusion criteria has never been compared. We explored the exclusion criteria used in psychotherapy and pharmacotherapy studies from 1995 to 2014.

METHOD

Systematic literature searches were conducted in PubMed, Medline, PsycINFO, and Embase of published randomized controlled trials (RCTs) of the treatment of major depressive disorder (MDD) in adults with either antidepressants (vs. placebos) or psychotherapy (vs. placebos, treatments as usual, or other controls).

RESULTS

Most psychotherapy (81%) and antidepressant (100%) trials excluded patients with milder symptoms as well as patients with elevated suicidal risk (56-75%), psychotic symptoms (84-88%), or substance misuse (75-81%). Psychotherapy studies were less likely to exclude patients on the basis of brief episode duration (0% vs. 48%) and co-morbid Axis I disorders (6% vs. 27%). However, psychotherapy studies excluded patients with more severe symptoms more frequently (38%) than antidepressant studies (8%).

CONCLUSIONS

Overall, psychotherapy studies appear somewhat more inclusive than antidepressant studies. On average, antidepressant studies appear to target patients with more chronic and severe, as well as more purely depressive presentations.

Moderation of the Alliance-Outcome Association by Prior Depressive Episodes: Differential Effects in Cognitive-Behavioral Therapy and Short-Term Psychodynamic Supportive Psychotherapy

Prior studies have suggested that the association between the alliance and depression improvement varies as a function of prior history of depression. We sought to replicate these findings and extend them to short-term psychodynamic supportive psychotherapy (SPSP) in a sample of patients who were randomized to one of these treatments and were administered the Helping Alliance Questionnaire (N=282) at Week 5 of treatment. Overall, the alliance was a predictor of symptom change (d=0.33). In SPSP, the alliance was a modest but robust predictor of change, irrespective of prior episodes (d=0.25-0.33). By contrast, in CBT, the effects of the alliance on symptom change were large for patients with 0 prior episodes (d=0.86), moderate for those with 1 prior episode (d=0.49), and small for those with 2+ prior episodes (d=0.12). These findings suggest a complex interaction between patient features and common vs. specific therapy processes. In CBT, the alliance relates to change for patients with less recurrent depression whereas other CBT-specific processes may account for change for patients with more recurrent depression.

Under-diagnosis of mood disorders in Canada

AIMS

Under-diagnosis of mood disorders occurs worldwide. In this study, we characterized and compared Canadians with symptoms compatible with a mood disorder by diagnosis status; and described the associated health impacts, use of health services and perceived need for care.

METHODS

Respondents to the 2012 Canadian Community Health Survey - Mental Health, a nationally representative sample of Canadians age ≥15 years were assessed for symptoms compatible with mood disorders based on a Canadian adaptation of the World Health Organization Composite International Diagnostic Interview (n = 23 504). Descriptive and multivariate regression analyses were performed.

RESULTS

In 2012, an estimated 5.4% (1.5 million) Canadians aged 15 years and older reported symptoms compatible with a mood disorder, of which only half reported having been professionally diagnosed. The undiagnosed individuals were more likely to be younger (mean age: 36.2 v. 41.8), to be single (49.5 v. 32.7%), to have less than a post-secondary graduation (49.8 v. 41.1%) and to have no physical co-morbidities (56.4 v. 35.7%), and less likely to be part of the two lower income quintiles (49.6 v. 62.7%) compared with those with a previous diagnosis. Upon controlling for all socio-demographic and health characteristics, the associations with age and marital status disappeared. While those with a previous diagnosis reported significantly greater health impacts and were more likely to have consulted a health professional for their emotional and mental health problems in the previous 12 months compared with those undiagnosed (79.4 v. 31.0%), about a third of both groups reported that their health care needs were only partially met or not met at all.

CONCLUSIONS

Mood disorders are prevalent and can profoundly impact the life of those affected, however, their diagnosis remains suboptimal and health care use falls short of apparent needs. Improvements in mental health literacy, help-seeking behaviours and diagnosis are needed. In light of the heterogeneity of mood disorders in terms of symptoms severity, impacts and prognosis, interventions must be tailored accordingly.

A prognostic index (PI) as a moderator of outcomes in the treatment of depression: A proof of concept combining multiple variables to inform risk-stratified stepped care models

BACKGROUND

Prognostic indices (PIs) combining variables to predict future depression risk may help guide the selection of treatments that differ in intensity. We develop a PI and show its promise in guiding treatment decisions between treatment as usual (TAU), treatment starting with a low-intensity treatment (brief therapy (BT)), or treatment starting with a high-intensity treatment intervention (cognitive-behavioral therapy (CBT)).

METHODS

We utilized data from depressed patients (N=622) who participated in a randomized comparison of TAU, BT, and CBT in which no statistically significant differences in the primary outcomes emerged between the three treatments. We developed a PI by predicting depression risk at follow-up using a LASSO-style bootstrap variable selection procedure. We then examined between-treatment differences in outcome as a function of the PI.

RESULTS

Unemployment, depression severity, hostility, sleep problems, and lower positive emotionality at baseline predicted a lower likelihood of recovery across treatments. The PI incorporating these variables produced a fair classification accuracy (c=0.73). Among patients with a high PI (75% percent of the sample), recovery rates were high and did not differ between treatments (79-86%). Among the patients with the poorest prognosis, recovery rates were substantially higher in the CBT condition (60%) than in TAU (39%) or BT (44%).

LIMITATIONS

No information on additional treatment sought. Prospective tests needed.

CONCLUSION

Replicable PIs may aid treatment selection and help streamline stepped models of care. Differences between treatments for depression that differ in intensity may only emerge for patients with the poorest prognosis.

Using Clinical Characteristics to Identify Which Patients With Major Depressive Disorder Have a Higher Genetic Load for Three Psychiatric Disorders

BACKGROUND

Limited successes of gene finding for major depressive disorder (MDD) may be partly due to phenotypic heterogeneity. We tested whether the genetic load for MDD, bipolar disorder, and schizophrenia (SCZ) is increased in phenotypically more homogenous MDD patients identified by specific clinical characteristics.

METHODS

Patients (n = 1539) with a DSM-IV MDD diagnosis and control subjects (n = 1792) were from two large cohort studies (Netherlands Study of Depression and Anxiety and Netherlands Twin Register). Genomic profile risk scores (GPRSs) for MDD, bipolar disorder, and SCZ were based on meta-analysis results of the Psychiatric Genomics Consortium. Regression analyses (adjusted for year of birth, sex, three principal components) examined the association between GPRSs with characteristics and GPRSs with MDD subgroups stratified according to the most relevant characteristics. The proportion of liability variance explained by GPRSs for each MDD subgroup was estimated.

RESULTS

GPRS-MDD explained 1.0% (p = 4.19e^-09) of MDD variance, and 1.5% (p = 4.23e^-09) for MDD endorsing nine DSM symptoms. GPRS-bipolar disorder explained 0.6% (p = 2.97e^-05) of MDD variance and 1.1% (p = 1.30e^-05) for MDD with age at onset <18 years. GPRS-SCZ explained 2.0% (p = 6.15e^-16) of MDD variance, 2.6% (p = 2.88e^-10) for MDD with higher symptom severity, and 2.3% (p = 2.26e^-13) for MDD endorsing nine DSM symptoms. An independent sample replicated the same pattern of stronger associations between cases with more DSM symptoms, as compared to overall MDD, and GPRS-SCZ.

CONCLUSIONS

MDD patients with early age at onset and higher symptom severity have an increased genetic risk for three major psychiatric disorders, suggesting that it is useful to create phenotypically more homogenous groups when searching for genes associated with MDD.

Consensus paper of the WFSBP Task Force on Genetics: Genetics, epigenetics and gene expression markers of major depressive disorder and antidepressant response

Major depressive disorder (MDD) is a heritable disease with a heavy personal and socio-economic burden. Antidepressants of different classes are prescribed to treat MDD, but reliable and reproducible markers of efficacy are not available for clinical use. Further complicating treatment, the diagnosis of MDD is not guided by objective criteria, resulting in the risk of under- or overtreatment. A number of markers of MDD and antidepressant response have been investigated at the genetic, epigenetic, gene expression and protein levels. Polymorphisms in genes involved in antidepressant metabolism (cytochrome P450 isoenzymes), antidepressant transport (ABCB1), glucocorticoid signalling (FKBP5) and serotonin neurotransmission (SLC6A4 and HTR2A) were among those included in the first pharmacogenetic assays that have been tested for clinical applicability. The results of these investigations were encouraging when examining patient-outcome improvement. Furthermore, a nine-serum biomarker panel (including BDNF, cortisol and soluble TNF-α receptor type II) showed good sensitivity and specificity in differentiating between MDD and healthy controls. These first diagnostic and response-predictive tests for MDD provided a source of optimism for future clinical applications. However, such findings should be considered very carefully because their benefit/cost ratio and clinical indications were not clearly demonstrated. Future tests may include combinations of different types of biomarkers and be specific for MDD subtypes or pathological dimensions.

Relationship between personality and psychopathology in a longitudinal community study: a test of the predisposition model

BACKGROUND

Mounting evidence supports the notion that personality is crucial in the aetiopathology of common mental disorders, but studies that allow for aetiological conclusions are lacking. The aim of the present study was thus to provide a test of the predisposition model.

METHOD

We analysed data from the Zurich Cohort Study, a 30-year longitudinal epidemiological community study of an adult cohort (n = 591) from 1979 to 2008. Personality was assessed in 1988 with an established personality questionnaire, and psychopathology through seven semi-structured interviews between 1979 and 2008.

RESULTS

On the basis of personality assessment from 1988, used as predictor of subsequent psychopathology (1993-2008), while adjusting for sex and prior mental disorders (1979-1988), neuroticism related significantly with future major depression episodes [odds ratio (OR) = 1.41], anxiety disorders (OR = 1.32) and depression treatment use (OR = 1.41). When participants with a past 10-year history (i.e. 1979-1988) of either major depression, anxiety disorder or depression treatment use were excluded, neuroticism in 1988 still significantly predicted first incidence (i.e. 1993-2008) of major depression episodes (OR = 1.53) and depression treatment use (OR = 1.84).

CONCLUSIONS

The present study provides compelling evidence that the personality trait of neuroticism constitutes an independent risk factor for subsequent major depression episodes and use of respective professional treatments, which serves as a proxy for particularly severe and impairing depression episodes. We therefore advocate that personality traits could provide clinically useful prognostic information when considered carefully.

Major depressive disorder: reification and (maybe) rheostasis

The heterogeneity of clinical syndromes subsumed by diagnostic criteria for major depressive disorder (MDD) is regarded by some as a reason to abandon or modify the criteria. However, heterogeneity may be unavoidable because of the biopsychosocial complexity of depression. MDD may be characterised by complexities that cannot be distilled down to any brief set of diagnostic criteria. Psychiatrists and psychiatric epidemiologists may need to revise their expectations of this diagnosis in order to avoid over-estimating its ability to guide the selection of treatments and prediction of prognosis. An opposing perspective is that of reification, in which the diagnosis is viewed as being more real than it really is. The concept of rheostasis may help to explain some features of this condition, such as why major depressive episodes sometimes seem understandable or even adaptive (e.g. in the context of bereavement) whereas at other times such episodes are inexplicable and maladaptive.