1
|
Sahker E, Furukawa TA, Luo Y, Ferreira ML, Okazaki K, Chevance A, Markham S, Ede R, Leucht S, Cipriani A, Salanti G. Estimating the smallest worthwhile difference of antidepressants: a cross-sectional survey. BMJ MENTAL HEALTH 2024; 27:e300919. [PMID: 38191234 PMCID: PMC10806871 DOI: 10.1136/bmjment-2023-300919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/11/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Approximately 30% of patients experience substantial improvement in depression after 2 months without treatment, and 45% with antidepressants. The smallest worthwhile difference (SWD) refers to an intervention's smallest beneficial effect over a comparison patients deem worthwhile given treatment burdens (harms, expenses and inconveniences), but is undetermined for antidepressants. OBJECTIVE Estimating the SWD of commonly prescribed antidepressants for depression compared to no treatment. METHODS The SWD was estimated as a patient-required difference in response rates between antidepressants and no treatment after 2 months. An online cross-sectional survey using Prolific, MQ Mental Health and Amazon Mechanical Turk crowdsourcing services in the UK and USA between October 2022 and January 2023 garnered participants (N=935) that were a mean age of 44.1 (SD=13.9) and 66% women (n=617). FINDINGS Of 935 participants, 124 reported moderate-to-severe depressive symptoms but were not in treatment, 390 were in treatment and 495 reported absent-to-mild symptoms with or without treatment experiences. The median SWD was a 20% (IQR=10-30%) difference in response rates for people with moderate-to-severe depressive symptoms, not in treatment, and willing to consider antidepressants, and 25% (IQR=10-35%) for the full sample. CONCLUSIONS Our observed SWDs mean that the current 15% antidepressant benefit over no treatment was sufficient for one in three people to accept antidepressants given the burdens, but two in three expected greater treatment benefits. IMPLICATIONS While a minority may be satisfied with the best currently available antidepressants, more effective and/or less burdensome medications are needed, with more attention given to patient perspectives.
Collapse
Affiliation(s)
- Ethan Sahker
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
- Population Health and Policy Research Unit, Medical Education Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Yan Luo
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
- Population Health and Policy Research Unit, Medical Education Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Manuela L Ferreira
- The University of Sydney, Sydney Musculoskeletal Health and The Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | | | - Astrid Chevance
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, France
| | - Sarah Markham
- Patient and Public Involvement (PPI) Group, Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College, London, UK
| | - Roger Ede
- Patient and Public Involvement (PPI) Group, Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, München, Germany
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine and Clinical Trials, University of Bern, Bern, Switzerland
| |
Collapse
|
2
|
Lippold B, Tarkunde YR, Cheng AL, Hannon CP, Adelani MA, Calfee RP. Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses. Arthroplast Today 2022; 15:215-219.e1. [PMID: 35774874 PMCID: PMC9237258 DOI: 10.1016/j.artd.2022.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications. Material and methods This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms. Results Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (β 7.1; P < .001) and with medication (β 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (β 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001). Conclusion One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.
Collapse
Affiliation(s)
- Brandon Lippold
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Yash R. Tarkunde
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Abby L. Cheng
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Charles P. Hannon
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Muyibat A. Adelani
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan P. Calfee
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| |
Collapse
|
3
|
Schroder HS, Patterson EH, Hirshbein L. Treatment-resistant depression reconsidered. SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
4
|
Sanwald S, Widenhorn-Müller K, Schönfeldt-Lecuona C, Montag C, Kiefer M. Factors related to age at depression onset: the role of SLC6A4 methylation, sex, exposure to stressful life events and personality in a sample of inpatients suffering from major depression. BMC Psychiatry 2021; 21:167. [PMID: 33765975 PMCID: PMC7995700 DOI: 10.1186/s12888-021-03166-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/12/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND An early onset of depression is associated with higher chronicity and disability, more stressful life events (SLEs), higher negative emotionality as described by the primary emotion SADNESS and more severe depressive symptomatology compared to depression onset later in life. Additionally, methylation of the serotonin transporter gene (SLC6A4) is associated with SLEs and depressive symptoms. METHODS We investigated the relation of SLEs, SLC6A4 methylation in peripheral blood, the primary emotions SADNESS and SEEKING (measured by the Affective Neuroscience Personality Scales) as well as depressive symptom severity to age at depression onset in a sample of N = 146 inpatients suffering from major depression. RESULTS Depressed women showed higher SADNESS (t (91.05) = - 3.17, p = 0.028, d = - 0.57) and higher SLC6A4 methylation (t (88.79) = - 2.95, p = 0.02, d = - 0.55) compared to men. There were associations between SLEs, primary emotions and depression severity, which partly differed between women and men. The Akaike information criterion (AIC) indicated the selection of a model including sex, SLEs, SEEKING and SADNESS for the prediction of age at depression onset. SLC6A4 methylation was not related to depression severity, age at depression onset or SLEs in the entire group, but positively related to depression severity in women. CONCLUSIONS Taken together, we provide further evidence that age at depression onset is associated with SLEs, personality and depression severity. However, we found no associations between age at onset and SLC6A4 methylation. The joint investigation of variables originating in biology, psychology and psychiatry could make an important contribution to understanding the development of depressive disorders by elucidating potential subtypes of depression.
Collapse
Affiliation(s)
- Simon Sanwald
- Department of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany.
| | | | | | - Christian Montag
- Institute of Psychology and Education, Department of Molecular Psychology, Ulm University, Ulm, Germany
| | - Markus Kiefer
- Department of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany
| |
Collapse
|
5
|
Cochrane S, Dale AM, Buckner-Petty S, Sobel AD, Lippold B, Calfee RP. Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients. J Hand Surg Am 2021; 46:99-105. [PMID: 33277101 DOI: 10.1016/j.jhsa.2020.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 07/31/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE We aimed to test the utility of screening for depressive symptoms in the hand surgical office focusing on chances of heightened depressive symptoms in patients with no history of diagnosed depression and by quantifying ongoing depressive symptoms among patients diagnosed with depression accounting for antidepressant use. The clinical importance of this study was predicated on the documented negative association between depressive symptoms and hand surgical outcomes. METHODS This cross-sectional study analyzed 351 patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. Adult patients completed self-administered Patient-Reported Outcomes Measurement Information System (PROMIS) Depression computer adaptive tests at registration. Health records were examined for a past medical history of diagnosed depression and whether patients reported current use of prescription antidepressants. Mean PROMIS Depression scores were compared by analysis of variance (groups: no diagnosed depression, depression without medication, depression with medication). Four points represented a clinically relevant difference in PROMIS Depression scores between groups and Depression scores greater than 59.9 were categorized as having heightened depressive symptoms. RESULTS Sixty-two patients (18%) had been diagnosed with depression. Thirty-four of these patients (55%) reported taking antidepressant medications. The PROMIS Depression scores indicated greater current depressive symptoms among patients with a history of diagnosed depression when not taking antidepressants (11 points worse than unaffected) and also among patients taking antidepressants (7 points worse than unaffected). Heightened depressive symptoms were detected in all groups but were more prevalent among those diagnosed with depression (36% with no medication, 29% with antidepressant medication) compared with unaffected patients (7%). CONCLUSIONS Depression screening for heightened depressive symptoms identifies 1 in 14 patients without diagnosed depression and 1 in 3 patients diagnosed with depression as having currently heightened depressive symptoms. Hand surgeons can use PROMIS Depression screening in all patients and using this to guide referrals for depression treatment to ameliorate one confounder of hand surgical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Symptom prevalence study II.
Collapse
Affiliation(s)
- Shannon Cochrane
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Ann Marie Dale
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Skye Buckner-Petty
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Andrew D Sobel
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Brandon Lippold
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ryan P Calfee
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.
| |
Collapse
|
6
|
Wells H, Crowe M, Inder M. Why people choose to participate in psychotherapy for depression: A qualitative study. J Psychiatr Ment Health Nurs 2020; 27:417-424. [PMID: 31957177 DOI: 10.1111/jpm.12597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Medication does not always resolve a serious mood episode, and there is evidence that it needs to be combined with an evidence-based psychotherapy to promote symptomatic and functional recovery. There is little known about what people with serious mood disorders want from mental health services to manage their mood. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Participants in this study wanted a framework other than the medical model for understanding and managing their mood. Their motivation to commence psychotherapy was based on a sense of having hit rock bottom and a need for understanding what was happening in order to better manage their mood. ABSTRACT: Introduction There is little known about the motivations for people to participate in psychotherapy for depression. Aim To explore why people, with a diagnosis of major depressive episode, chose to take part in a psychotherapy study and what they expected it to involve. Method This was a qualitative study of participants' motivations and understandings of psychotherapy for depression. Data were collected using semi-structured interviews and analysed using thematic analysis. Findings Eight females and eight males with an age range from 21 years to 55 years were recruited. Three themes were identified that described why participants chose to participate in psychotherapy: medication was not enough, a turning point and making sense of experience. The participants chose to participate in psychotherapy after finding that medication was insufficient and this combined with a sense of crisis motivated them to engage in psychotherapy in order to learn to manage their mood differently. Discussion The participants recognized that they wanted a framework other than a medical model with its reliance on medication, in order to make sense of their experiences and develop new self-management strategies. Implications for Practice Our study suggests that some people experiencing a serious mood disorder access psychotherapy after "hitting rock bottom" and finding insufficient help from medications. Mental health nurses need to be aware people do not always want a medical model approach to treatment of serious mood disorders and they need to provide the opportunity of engaging in a psychotherapeutic framework in order to better understand and manage their mood.
Collapse
Affiliation(s)
- Hayley Wells
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Marie Crowe
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Maree Inder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| |
Collapse
|
7
|
Ormel J, Spinhoven P, de Vries YA, Cramer AOJ, Siegle GJ, Bockting CLH, Hollon SD. The antidepressant standoff: why it continues and how to resolve it. Psychol Med 2020; 50:177-186. [PMID: 31779735 DOI: 10.1017/s0033291719003295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antidepressant medications (ADMs) are widely used and long-term use is increasing. Given this extensive use and recommendation of ADMs in guidelines, one would expect ADMs to be universally considered effective. Surprisingly, that is not the case; fierce debate on their benefits and harms continues. This editorial seeks to understand why the controversy continues and how consensus can be achieved. METHODS 'Position' paper. Critical analysis and synthesis of relevant literature. RESULTS Advocates point at ADMs impressive effect size (number needed to treat, NNT = 6-8) in acute phase treatment and continuation/maintenance ADM treatment prevention relapse/recurrence in acute phase ADM responders (NNT = 3-4). Critics point at the limited clinically significant surplus value of ADMs relative to placebo and argue that effectiveness is overstated. We identified multiple factors that fuel the controversy: certainty of evidence is low to moderate; modest efficacy on top of strong placebo effects allows critics to focus on small net efficacy and advocates on large gross efficacy; ADM withdrawal symptoms masquerade as relapse/recurrence; lack of association between ADM treatment and long-term outcome in observational databases. Similar problems affect psychological treatments as well, but less so. We recommend four approaches to resolve the controversy: (1) placebo-controlled trials with relevant long-term outcome assessments, (2) inventive analyses of observational databases, (3) patient cohort studies including effect moderators to improve personalized treatment, and (4) psychological treatments as universal first-line treatment step. CONCLUSIONS Given the public health significance of depression and increased long-term ADM usage, new approaches are needed to resolve the controversy.
Collapse
Affiliation(s)
- Johan Ormel
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
| | - Philip Spinhoven
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
- Department of Psychiatry, Leiden University, Institute of Psychology, Leiden, The Netherlands
| | - Ymkje Anna de Vries
- Department of Developmental Psychology, University of Groningen, Groningen, The Netherlands
| | - Angélique O J Cramer
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
- Department of Methodology and Statistics, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Greg J Siegle
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Claudi L H Bockting
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
- Department of Psychiatry, University of Amsterdam, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
8
|
Holper L. Combining threshold analysis and GRADE to assess sensitivity to bias in antidepressant treatment recommendations adjusted for depression severity. Res Synth Methods 2019; 11:275-286. [PMID: 31873975 DOI: 10.1002/jrsm.1393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/07/2023]
Abstract
Threshold analysis has recently been proposed to be used in combination with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in order to assess the sensitivity to plausible bias of treatment recommendations derived from Bayesian network meta-analysis (NMA). Here, it was aimed to apply the combination of threshold analysis and GRADE to judge quantitative and qualitative information on risk of bias in antidepressant treatment recommendations. The analysis was based on the data set provided by Cipriani et al. (The Lancet 2018) comparing 21 antidepressants in adult major depressive disorder (MDD). Primary outcomes were efficacy (response rate) and acceptability (dropout rate) adjusted for the covariate depression severity. The combined approach suggested sensitivity to plausible bias to be largest for antidepressant recommendations top ranked by Cipriani et al., that is, amitriptyline, duloxetine, paroxetine, and venlafaxine in terms of efficacy and agomelatine, escitalopram, paroxetine, and venlafaxine in terms of acceptability. Covariate ranges within which recommendations were most sensitive to plausible bias were very severe depression in terms of efficacy (smallest threshold, ie, the largest sensitivity, around 39 Hamilton Depression Rating Scale [HDRS]) and moderate depression in terms of acceptability (smallest thresholds around 16 and 35 HDRS). This indicates that treatment recommendations within these ranges may likely change if plausible bias adjustments take place. The present findings may support decision makers in judging the sensitivity to plausible bias of current antidepressant treatment recommendations to accurately guide treatment decisions in MDD depending on depression severity.
Collapse
Affiliation(s)
- L Holper
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
9
|
Kunzke D, Thoma MV, Joksimovic L. Pharmako- und/oder Psychotherapie bei posttraumatischer Belastungsstörung. PSYCHOTHERAPEUT 2019. [DOI: 10.1007/s00278-019-0339-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
10
|
Depression: more treatment but no drop in prevalence: how effective is treatment? And can we do better? Curr Opin Psychiatry 2019; 32:348-354. [PMID: 30855297 DOI: 10.1097/yco.0000000000000505] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Since the 70s, treatment of depression, especially pharmacologically, has expanded enormously. However, epidemiological studies show that 12-month population prevalence rates have not dropped. This observation raises multiple questions. How good are treatments of depression actually? Do they improve long-term outcomes? Have the treatment gaps narrowed? And how can we make mental healthcare more effective at the population level? RECENT FINDINGS Recent publications suggest some answers. Controlled treatment trials show that effectiveness of specific treatments (pharmacological, psychological) is modest and probably overestimated owing to substantial spontaneous recovery and nonspecific therapeutic effects. Treatment gaps are still substantial and prevention has unclear long-term effects and is not structurally embedded. Future relevance of genetic information for better personalized treatment is potentially high but uncertain. Increasingly, the potential of treatment to improve long-term outcome is being questioned. SUMMARY To reduce prevalence, it is essential to narrow the treatment gaps, provide timely interventions and high-quality treatment, eradicate waiting lists, prescribe antidepressants more cautiously and better managed, consider psychological alternatives, and provide more psychosocial treatment in primary care with physician-assistants. In addition, research is needed on long-term outcome of different treatment modalities, and least but not last the value of structurally socially embedded preventive interventions.
Collapse
|