Predictors of 1-year outcome in depression

Effect of pimavanserin on anxious depression in patients with major depression and an inadequate response to previous therapy: secondary analysis of the clarity study

In a post hoc analysis, the effect of pimavanserin on anxious depression was determined from CLARITY, a randomized, double-blind, placebo-controlled study in patients with major depression and an inadequate response to previous therapy. Patients were randomized in a 3:1 ratio to placebo or pimavanserin 34 mg daily added to ongoing antidepressant therapy. At 5 weeks, placebo nonresponders were rerandomized to placebo or pimavanserin for an additional 5 weeks. Mean change from baseline to week 5 for the Hamilton depression rating scale (HAMD) anxiety/somatization (AS) factor was examined for all patients and those with a score ≥7 at baseline. Least squares (LS) mean [standard error (SE)] difference between placebo and pimavanserin for the AS factor score was -1.5 (0.41) [95% confidence interval (CI) -2.4 to -0.7; P = 0.0003; effect size: 0.634]. Among patients with an AS factor score ≥7 at baseline, LS mean (SE) difference was -2.2 (0.66) (95% CI -3.5 to -0.9; P = 0.0013; effect size: 0.781). Response rates (≥50% reduction in HAMD-17 from baseline) were 22.4 and 55.2% (P = 0.0012) and remission rates (HAMD-17 total score <7) were 5.3 and 24.1% (P = 0.0047), respectively, with placebo and pimavanserin among patients with a baseline AS factor score ≥7. Among patients with anxious major depressive disorder at baseline, adjunctive pimavanserin was associated with a significant improvement.

Standardisation framework for the Maudsley staging method for treatment resistance in depression

BACKGROUND

Treatment-resistant depression (TRD) is a serious and relatively common clinical condition. Lack of consensus on defining and staging TRD remains one of the main barriers to understanding TRD and approaches to intervention. The Maudsley Staging Method (MSM) is the first multidimensional model developed to define and stage treatment-resistance in "unipolar depression". The model is being used increasingly in treatment and epidemiological studies of TRD and has the potential to support consensus. Yet, standardised methods for rating the MSM have not been described adequately. The aim of this report is to present standardised approaches for rating or completing the MSM.

METHOD

Based on the initial development of the MSM and a narrative review of the literature, the developers of the MSM provide explicit guidance on how the three dimensions of the MSM--treatment failure, severity of depressive episode and duration of depressive episode-- may be rated.

RESULT

The core dimension of the MSM, treatment failure, may be assessed using the Maudsley Treatment Inventory (MTI), a new method developed for the purposes of completing the MSM. The MTI consists of a relatively comprehensive list of medications with options for rating doses and provisions treatment for multiple episodes. The second dimension, severity of symptoms, may be assessed using simple instruments such as the Clinical Global Impression, the Psychiatric Status Rating or checklist from a standard diagnostic checklist. The standardisation also provides a simple rating scale for scoring the third dimension, duration of depressive episode.

CONCLUSION

The approaches provided should have clinical and research utility in staging TRD. However, in proposing this model, we are fully cognisant that until the pathophysiology of depression is better understood, staging methods can only be tentative approximations. Future developments should attempt to incorporate other biological/ pathophysiological dimensions for staging.

Rate and Predictors of Persistent Major Depressive Disorder in a Nationally Representative Sample

This study examined predictors of persistent major depressive disorder over 10 years, focusing on the effects of clinical variables, physical health, and social support. Data from the National Survey of Midlife Development in the United States in 1995-1996 and 2004-2006 were analyzed. Logistic regression was used to predict non-recovery from major depression among individuals who met clinical-based criteria for major depressive disorder at baseline. Fifteen percent of the total sample was classified as having major depression in 1995-1996; of these individuals, 37 % had major depression in 2004-2006. Baseline variables that were significantly associated with persistent major depression at follow-up were being female, having never married, having two or more chronic medical conditions, experiencing activity limitation, and less contact with family. Therefore, treatment strategies focused on physical health, social support, and mental health needs are necessary to comprehensively address the factors that contribute to persistent major depressive disorder.

Comparison of personality beliefs between depressed patients and healthy controls

INTRODUCTION

According to the cognitive model, the common mechanism underlying all psychological disorders is distorted or dysfunctional thoughts that affect mood and behaviors. Dysfunctional thoughts predispose an individual to depression and are among the processes that form the basis of personality traits. Elucidating the personality beliefs associated with depression and dysfunctional thoughts is important to understanding and treating depression. The aim of the present study is to determine whether depressed patients exhibited pathological personality beliefs compared with healthy controls. Furthermore, we investigated which personality beliefs were more common among such depressed patients.

METHODS

A total of 70 patients who were admitted to the Department of Psychiatry at Ankara Diskapi Yildirim Beyazit Training and Research Hospital (Ankara, Turkey) and diagnosed with major depressive disorder according to The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnostic criteria were included in the study. Additionally, 70 healthy controls matched for age, marital status, and education were included in the study. The Sociodemographic Data Form and Personality Belief Questionnaire-Short form (PBQ-SF) were administered to the participants.

RESULTS

A comparison of the depression group with the healthy controls revealed higher scores in dependent, passive-aggressive, obsessive-compulsive, antisocial, histrionic, paranoid, borderline, and avoidant personality subscales in the depressive group.

CONCLUSIONS

These results suggest that personality beliefs at the pathological level are more common in depressive patients and that the detection of these beliefs would be useful for predicting the prognosis of the disease and determining appropriate treatment methods.

Bouncing back: remission from depression in a 12-year panel study of a representative Canadian community sample

PURPOSE

This study sought to investigate time to remission from depression in a community-based sample of adults followed for 12 years.

METHODS

Data were derived from the National Population Health Survey (1994/5-2006/7 and 1996/7-2008/9). Fully 1,128 adults were included who were depressed at baseline according to DSM-III/CIDI-SF criteria. Kaplan-Meier and Cox proportional hazards procedures were used to determine time to remission and the demographic (e.g., gender and marital status), psychosocial (e.g., social support and adverse childhood experience) and health-related (e.g., pain, health conditions and alcohol use) factors with which it is associated.

RESULTS

More than three quarters of the sample (77 %) no longer screened positive for depression at 2 years, and nearly the entire sample (94 %) had remitted by 12 years. Adverse childhood experiences (i.e., childhood abuse and parental additions), lack of social support, the presence of pain and health conditions (i.e., migraines, arthritis and back pain) each predicted more time to remission. The only factor associated with time to remission in the multivariate analysis was a history of childhood physical abuse.

CONCLUSIONS

Most community members with depression get better after 2 years and nearly all will have remitted, at least once, by 12 years. The results of this study may help guide the development of interventions for chronic depression that focus on early prevention of childhood abuse.

Personality disorders and outcome of inpatient treatment for depression: a 1-year prospective follow-up study

This study examines the relationship of personality disorders (PDs) with the outcome of an inpatient treatment for depression. One hundred sixty-eight inpatients with unipolar depression (41% with PD according to SCID-II) were assessed at admission, discharge, and 1-year follow-up. Patients without as well as with PD showed a significant and comparable intake-to-discharge symptom reduction in all inventories. At posttreatment, patients with PD scored higher in self-report measures of symptom severity (Brief Symptom Inventory, Beck Depression Inventory) than patients without PD, due to their higher symptom levels at intake. However, there was no difference in clinician-rated therapy outcome (Hamilton Rating Scale for Depression [17-item version], Global Assessment of Functioning Scale, Clinical Global Impression Scale) between both patient groups at discharge. At 1-year follow-up, patients without PD maintained their treatment outcome, whereas patients with PD showed a slight increase in symptom severity, compared to discharge. The results suggest that a difference in acute treatment outcome between depressed patients with and without PD may be found using self-ratings but not expert ratings of symptom severity. Furthermore, the importance of subsequent outpatient treatment that takes into account the special needs of depressed patients with comorbid PD is highlighted.

Time to rehospitalization in patients with major depression vs. those with schizophrenia or bipolar I disorder in a public psychiatric hospital

Compared rehospitalization rates in patients with schizophrenia or bipolar I disorder to patients with major depressive disorder remains unclear. This study aimed to compare the time to rehospitalization of the three groups. Other clinical variables were also examined. Rehospitalization status was monitored for all admitted inpatients with schizophrenia (n=637), bipolar I disorder (n=197), or major depressive disorder (n=191), from January 1, 2006 to December 31, 2006. Time to rehospitalization within 1 year after discharge was measured using the Kaplan-Meier method. Risk factors associated with rehospitalization were examined using the Cox proportional hazards regression model. The three groups were comparable for comorbid alcohol abuse/dependence, family history of severe psychiatric illness, years of education, and number of previous hospitalizations. No significant differences were noted among the three groups for the time to rehospitalization or the time to discontinuation. Age onset and number of previous admission were associated with risks of rehospitalization. This study suggests that the major depressive disorder, schizophrenia, and bipolar I disorder have comparable influences on time to rehospitalization and discontinuation from treatment and that earlier onset of illness and more previous hospitalizations are associated with higher risks of rehospitalization. Further prospective research is warranted.

Course and outcome of depressive disorders in primary care: a prospective 18-month study

BACKGROUND

Depressive disorders are known to often be chronic and recurrent both in the general population and in psychiatric settings. However, despite its importance for public health and services, the outcome of depression in primary care is not well known.

METHOD

In The Vantaa Primary Care Depression Study (PC-VDS), 1111 consecutive primary-care patients were screened for depression with the Prime-MD screen, and 137 diagnosed with DSM-IV depressive disorders by interviewing with the Structured Clinical Interview for DSM-IV (SCID)-I/P and SCID-II. This cohort was prospectively followed-up at 3, 6 and 18 months. Altogether 123 patients (90%) completed the 18-month follow-up, including 79 with major depressive disorder (MDD) and 44 with subsyndromal disorders. Duration of the index episode and the timing of relapses/recurrences were examined using a life-chart.

RESULTS

Of the patients with MDD, only a quarter [25% (20/79)] achieved and remained in full remission, while another quarter [25% (20/79)] persisted in major depressive episode for 18 months. The remaining 49% (39/79) suffered from residual symptoms or recurrences. In Cox regression models, time to remission and recurrences were robustly predicted by severity of depression, and less consistently by co-morbid substance-use disorder, chronic medical illness or cluster C personality disorder. Of the subsyndromal patients, 25% (11/44) proceeded to MDD.

CONCLUSIONS

This prospective medium-term study verified the high rate of recurrences and chronicity of depression also in primary care. Severity of depressive symptoms and co-morbidity are important predictors of outcome. Development of chronic disease management for depression is warranted in primary care.

Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone

The main aim of the present novel reanalysis of archival data was to compare the time to remission during 12 weeks of treatment of chronic depression following antidepressant medication (n = 218), psychotherapy (n = 216), and their combination (n = 222). Cox regression survival analyses revealed that the combination of medication and psychotherapy produced full remission from chronic depression more rapidly than either of the single modality treatments, which did not differ from each other. Receiver operating characteristic curve analysis was used to explore predictors (treatment group, demographic, clinical, and psychosocial) of remission. For those receiving the combination treatment, the most likely to succeed were those with low baseline depression (24-item Hamilton Rating Scale for Depression [HRSD; M. Hamilton, 1967] score < 26) and those with high depression scores but low anxiety (HRSD = 26 and Hamilton Anxiety Rating Scale [M. Hamilton, 1959] < 14). Both profiles were associated with at least 40% chance of attaining full remission. The model did not identify predictors for those receiving medication or psychotherapy alone, and it did not distinguish between the 2 monotherapies. The authors conclude that combined antidepressant medications and psychotherapy result in faster full remission of chronic forms of major depressive disorder.

Transtornos de humor refratários a tratamento

OBJETIVOS E MÉTODO: Os transtornos de humor estão entre os transtornos psiquiátricos mais prevalentes. Apesar de novas descobertas e avanços no estudo das bases neurobiológicas e abordagens terapêuticas no transtorno bipolar e depressão recorrente, elevadas taxas de recorrência, sintomas subsindrômicos persistentes e refratariedade terapêutica são aspectos clínicos desafiadores e precisam ser abordados. O objetivo desta revisão da literatura é o de avaliar os conceitos e critérios de resistência e refratariedade ao tratamento, e evidenciar as principais alternativas terapêuticas para transtornos do humor resistentes aos tratamentos disponíveis. RESULTADOS: Fatores genéticos, erro diagnóstico e de tratamento, não-aderência, e estressores biológicos e psicossociais podem levar à perda de mecanismos regulatórios e ao aumento na prevalência de casos de refratariedade nos transtornos de humor. Com relação aos tratamentos disponíveis, o uso de doses apropriadas, seguido por associação com um segundo ou terceiro fármaco, e após, se indicado, a troca de medicação, são etapas necessárias na busca de melhor eficácia. Entretanto, no paradigma de refratariedade terapêutica, tratamentos atuando em sistemas já conhecidos, especialmente monoaminas, freqüentemente apresentam limitada eficácia. Assim, a busca por tratamentos mais eficazes para os transtornos de humor torna-se um aspecto chave para diminuir sua morbidade. CONCLUSÃO: Estratégias focadas na regulação de vias ativadoras de neuroplasticidade, incluindo agentes antiglutamatérgicos, antagonistas de receptor glucocorticóide e neuropeptídeos, podem representar opções terapêuticas promissoras.

Mental health of US Gulf War veterans 10 years after the war

BACKGROUND

Gulf War veterans reported multiple psychological symptoms immediately after the war; the temporal course of these symptoms remains unclear.

AIMS

To assess the prevalence of war era onset mental disorders in US veterans deployed to the Gulf War and in non-deployed veterans 10 years after the war.

METHOD

Mental disorders were diagnosed using structured clinical interviews. Standard questionnaires assessed symptoms and quality of life.

RESULTS

Gulf War-era onset mental disorders were more prevalent in deployed veterans (18.1%, n=1061) compared with non-deployed veterans (8.9%, n=1128). The prevalence of depression and anxiety declined 10 years later in both groups, but remained higher in the deployed group, who also reported more symptoms and a lower quality of life than the non-deployed group. Remission of depression may be related to the presence of comorbid psychiatric disorders and level of education. Remission of anxiety was related to treatment with medication.

CONCLUSIONS

Gulf War deployment was associated with an increased prevalence of mental disorders, psychological symptoms and a lower quality of life beginning during the war and persisting at a lower rate 10 years later.