Association between medical comorbidity and treatment outcomes in late-life depression

Sleep Delta power, age, and sex effects in treatment-resistant depression

Electroencephalographic (EEG) deficits in slow wave activity or Delta power (0.5-4 Hz) indicate disturbed sleep homeostasis and are hallmarks of depression. Sleep homeostasis is linked to restorative sleep and potential antidepressant response via non-rapid eye movement (NREM) slow wave sleep (SWS) during which neurons undergo essential repair and rejuvenation. Decreased Low Delta power (0.5-2 Hz) was previously reported in individuals with depression. This study investigated power levels in the Low Delta (0.5-<2 Hz), High Delta (2-4 Hz), and Total Delta (0.5-4 Hz) bands and their association with age, sex, and disrupted sleep in treatment-resistant depression (TRD). Mann-Whitney U tests were used to compare the nightly progressions of Total Delta, Low Delta, and High Delta in 100 individuals with TRD and 24 healthy volunteers (HVs). Polysomnographic parameters were also examined, including Total Sleep Time (TST), Sleep Efficiency (SE), and Wake after Sleep Onset (WASO). Individuals with TRD had lower Delta power during the first NREM episode (NREM1) than HVs. The deficiency was observed in the Low Delta band versus High Delta. Females with TRD had higher Delta power than males during the first NREM1 episode, with the most noticeable sex difference observed in Low Delta. In individuals with TRD, Low Delta power correlated with WASO and SE, and High Delta correlated with WASO. Low Delta power deficits in NREM1 were observed in older males with TRD, but not females. These results provide compelling evidence for a link between age, sex, Low Delta power, sleep homeostasis, and non-restorative sleep in TRD.

Why is it so hard to identify (consistent) predictors of treatment outcome in psychotherapy? - clinical and research perspectives

BACKGROUND

Anxiety and depression are two of the most debilitating psychological disorders worldwide today. Fortunately, effective treatments exist. However, a large proportion of patients do not recover from treatment, and many still have symptoms after completing treatment. Numerous studies have tried to identify predictors of treatment outcome. So far, researchers have found few or no consistent predictors applicable to allocate patients to relevant treatment.

METHODS

We set out to investigate why it is so hard to identify (consistent) predictors of treatment outcome for psychotherapy in anxiety and depression by reviewing relevant literature.

RESULTS

Four challenges stand out; a) the complexity of human lives, b) sample size and statistical power, c) the complexity of therapist-patient relationships, and d) the lack of consistency in study designs. Together these challenges imply there are a countless number of possible predictors. We also consider ethical implications of predictor research in psychotherapy. Finally, we consider possible solutions, including the use of machine learning, larger samples and more realistic complex predictor models.

CONCLUSIONS

Our paper sheds light on why it is so hard to identify consistent predictors of treatment outcome in psychotherapy and suggest ethical implications as well as possible solutions to this problem.

Treatment-Resistant Late-Life Depression: A Review of Clinical Features, Neuropsychology, Neurobiology, and Treatment

Major depression is common in older adults (≥ 60 years of age), termed late-life depression (LLD). Up to 30% of these patients will have treatment-resistant late-life depression (TRLLD), defined as depression that persists despite two adequate antidepressant trials. TRLLD is challenging for clinicians, given several etiological factors (eg, neurocognitive conditions, medical comorbidities, anxiety, and sleep disruption). Proper assessment and management is critical, as individuals with TRLLD often present in medical settings and suffer from cognitive decline and other marks of accelerated aging. This article serves as an evidence-based guide for medical practitioners who encounter TRLLD in their practice.

Interactive Effects of Serum Leptin Levels and Physical Comorbidity on the Pharmacotherapeutic Response of Depressive Disorders

OBJECTIVE

To investigate individual and interactive associations of baseline serum leptin levels and physical comorbidity with short- and long-term treatment outcomes in outpatients with depressive disorders who received stepwise antidepressant treatment in a naturalistic prospective study design.

METHODS

Baseline serum leptin levels were measured, and the number of concurrent physical disorders ascertained from 1,094 patients. These patients received initial antidepressant monotherapy; then, for patients with an insufficient response or who experienced uncomfortable side effects, treatment was administered using alternative strategies every 3 weeks in the acute treatment phase (at 3, 6, 9, and 12 weeks) and every 3 months in the continuation treatment phase (at 6, 9, and 12 months). Then, 12-week and 12-month remission, defined as a Hamilton Depression Rating Scale score of ≤7, was estimated.

RESULTS

In multivariable logistic regression analyses, individual effects were found only between higher baseline serum leptin levels and 12-week non-remission. Significant interactive effects between higher leptin levels and fewer physical disorders (< 2 physical disorders) on 12-week non-remission were observed. However, neither individual nor interactive effects between leptin levels and physical comorbidity were associated with 12-month remission.

CONCLUSION

The combination of serum leptin level and number of physical disorders may be a useful predictor of short-term treatment responses in patients with depressive disorders receiving pharmacotherapy.

Transcranial Magnetic Stimulation Indices of Cortical Excitability Enhance the Prediction of Response to Pharmacotherapy in Late-Life Depression

BACKGROUND

Older adults with late-life depression (LLD) often experience incomplete or lack of response to first-line pharmacotherapy. The treatment of LLD could be improved using objective biological measures to predict response. Transcranial magnetic stimulation (TMS) can be used to measure cortical excitability, inhibition, and plasticity, which have been implicated in LLD pathophysiology and associated with brain stimulation treatment outcomes in younger adults with depression. TMS measures have not yet been investigated as predictors of treatment outcomes in LLD or pharmacotherapy outcomes in adults of any age with depression.

METHODS

We assessed whether pretreatment single-pulse and paired-pulse TMS measures, combined with clinical and demographic measures, predict venlafaxine treatment response in 76 outpatients with LLD. We compared the predictive performance of machine learning models including or excluding TMS predictors.

RESULTS

Two single-pulse TMS measures predicted venlafaxine response: cortical excitability (neuronal membrane excitability) and the variability of cortical excitability (dynamic fluctuations in excitability levels). In cross-validation, models using a combination of these TMS predictors, clinical markers of treatment resistance, and age classified patients with 73% ± 11% balanced accuracy (average correct classification rate of responders and nonresponders; permutation testing, p < .005); these models significantly outperformed (corrected t test, p = .025) models using clinical and demographic predictors alone (60% ± 10% balanced accuracy).

CONCLUSIONS

These preliminary findings suggest that single-pulse TMS measures of cortical excitability may be useful predictors of response to pharmacotherapy in LLD. Future studies are needed to confirm these findings and determine whether combining TMS predictors with other biomarkers further improves the accuracy of predicting LLD treatment outcome.

Vortioxetine in major depressive disorder: from mechanisms of action to clinical studies. An updated review

INTRODUCTION

Vortioxetine is a multimodal-acting antidepressant that provides improvements on cognitive function aside from antidepressants and anxiolytic effects. Vortioxetine has been found to be one of the most effective and best tolerated options for major depressive disorder (MDD) in head-to-head trials.

AREAS COVERED

The present review intends to gather the most relevant and pragmatic data of vortioxetine in MDD, specially focusing on new studies that emerged between 2015 and 2020.

EXPERT OPINION

Vortioxetine is the first antidepressant that has shown improvements both in depression and cognitive symptoms, due to the unique multimodal mechanism of action that combine the 5-HT reuptake inhibition with modulations of other key pre- and post-synaptic 5-HT receptors (agonism of 5-HT_1A receptor, partial agonism of 5-HT_1B receptor, and antagonism of 5-HT₃, 5-HT_1D and 5-HT₇ receptors). This new mechanism of action can explain the dose-dependent effect and can be responsible for its effects on cognitive functioning and improved tolerability profile. Potential analgesic and anti-inflammatory properties observed in preclinical studies as well as interesting efficacy and tolerability results of clinical studies with specific target groups render it a promising therapeutic option for patients with MDD and concomitant conditions (as menopause symptoms, pain, inflammation, apathy, sleep and/or metabolic abnormalities).

Bidirectional associations between treatment-resistant depression and general medical conditions

Depression is associated with general medical conditions (GMCs), but it is not known if treatment-resistant depression (TRD) affects GMC risk and vice versa. We estimated bidirectional associations between TRD and GMCs (prior and subsequent). All individuals aged 18-69 years, born and living in Denmark, with a first-time prescription for an antidepressant between 2005 and 2012 were identified in the Danish Prescription Registry (N = 154,513). TRD was defined as at least two shifts in treatment regimes. For prior GMCs, we estimated odds ratios (ORs) using conditional logistic regression comparing TRD patients with matched non-TRD controls adjusted for other GMCs and number of other GMCs. For subsequent GMCs, we used Cox regression to calculate hazard ratios (HRs) in TRD vs. non-TRD patients adjusted for age at first prescription, calendar time, other GMCs and number of other GMCs. Patients with TRD had higher prevalence of prior GMCs related to the immune or neurological systems; musculoskeletal disorders (women aOR: 1.35, 95% CI: 1.26-1.46, men aOR: 1.30, 95% CI: 1.19-1.42) and migraine (women aOR: 1.22, 95% CI: 1.09-1.36, men aOR: 1.25, 95% CI: 1.00-1.56). Subsequent GMCs were related to a broader spectrum; cardiovascular (women aHR: 1.43, 95% CI: 1.32-1.54, men aHR: 1.31, 95% CI: 1.19-1.43), endocrine (women aHR: 1.52, 95% CI: 1.37-1.67, men aHR: 1.24, 95% CI: 1.07-1.44), and neurological disorders (women aHR: 1.24, 95% CI: 1.13-1.35, men aHR: 1.19, 95% CI: 1.07-1.34). Our study presents a broad overview of comorbid medical conditions in patients with TRD and further studies are needed to explore the associations in detail.

Genome-wide analysis suggests the importance of vascular processes and neuroinflammation in late-life antidepressant response

Antidepressant outcomes in older adults with depression is poor, possibly because of comorbidities such as cerebrovascular disease. Therefore, we leveraged multiple genome-wide approaches to understand the genetic architecture of antidepressant response. Our sample included 307 older adults (≥60 years) with current major depression, treated with venlafaxine extended-release for 12 weeks. A standard genome-wide association study (GWAS) was conducted for post-treatment remission status, followed by in silico biological characterization of associated genes, as well as polygenic risk scoring for depression, neurodegenerative and cerebrovascular disease. The top-associated variants for remission status and percentage symptom improvement were PIEZO1 rs12597726 (OR = 0.33 [0.21, 0.51], p = 1.42 × 10^-6) and intergenic rs6916777 (Beta = 14.03 [8.47, 19.59], p = 1.25 × 10^-6), respectively. Pathway analysis revealed significant contributions from genes involved in the ubiquitin-proteasome system, which regulates intracellular protein degradation with has implications for inflammation, as well as atherosclerotic cardiovascular disease (n = 25 of 190 genes, p = 8.03 × 10^-6, FDR-corrected p = 0.01). Given the polygenicity of complex outcomes such as antidepressant response, we also explored 11 polygenic risk scores associated with risk for Alzheimer's disease and stroke. Of the 11 scores, risk for cardioembolic stroke was the second-best predictor of non-remission, after being male (Accuracy = 0.70 [0.59, 0.79], Sensitivity = 0.72, Specificity = 0.67; p = 2.45 × 10^-4). Although our findings did not reach genome-wide significance, they point to previously-implicated mechanisms and provide support for the roles of vascular and inflammatory pathways in LLD. Overall, significant enrichment of genes involved in protein degradation pathways that may be impaired, as well as the predictive capacity of risk for cardioembolic stroke, support a link between late-life depression remission and risk for vascular dysfunction.

Thymoquinone harbors protection against Concanavalin A-induced behavior deficit in BALB/c mice model

Global health estimates indicated approximately 322 million people living with depression. Rising cost of depressive illness treatment and non-responsiveness to existing therapies demand continued research to explore new and more potent therapies. Exploring the potential of natural compounds for their potent antidepressant potentials is becoming topic of interest for scientists. Anti-inflammatory activity of thymoquinone, the active ingredient of Nigella sativa, has been well documented. Current study tested thymoquinone for its antidepressant effect in a Concanavalin A (Con A)-induced depressive-like behavior in BALB/c mice. Thymoquinone successfully protected against Con A-induced behavioral despair and anxiety-like behavior. Reduced grooming behavior as a function of Con A treatment, was also reinstated. Underlying mechanism responsible for antidepressant activity of thymoquinone was analyzed by molecular docking. Thymoquinone interacts in halogen-binding pocket (HBP) of serotonin reuptake transporter indicating its potential as serotonin reuptake inhibitor. Results of current study anticipate thymoquinone as a potential antidepressant drug candidate. PRACTICAL APPLICATIONS: Black seeds of Nigella sativa are consumed with traditional and religious reference since centuries. Thymoquinone, active, and abundant component of Nigella sativa, has shown positive effects in multiple studies against arthritis, asthma, hepatic injury, neurodegeneration, and cancer owing to its immunomodulatory and anti-inflammatory attributes. Considering inflammation as one of central components involved in pathophysiology of major depressive disorder, thymoquinone has been evaluated in current study for its antidepressant potential. Positive results of current study propose thymoquinone as an affordable, natural antidepressant drug candidate with better safety profile than currently available antidepressant regimes. Thymoquinone might provide benefits against inflammation-related sickness behavior that is associated with poorer outcome of clinical depression, thus, paving the way for effective drug development against treatment-resistant depression.

Prognosis and Improved Outcomes in Major Depression: A Review

(Reprinted from Transl Psychiatry. 2019 Apr 3; 9(1):127. Open access; is licensed under a Creative Commons Attribution 4.0 International License).

How well do elderly patients with major depressive disorder respond to antidepressants: a systematic review and single-group meta-analysis

BACKGROUND

Depression is one of the leading causes of the global burden of disease, and it has particularly negative consequences for elderly patients. Antidepressants are the most frequently used treatment. We present the first single-group meta-analysis examining: 1) the response rates of elderly patients to antidepressants, and 2) the determinants of antidepressants response in this population.

METHODS

We searched multiple databases for randomized controlled trials on antidepressants in the elderly with major depressive disorder above 65 years (last search: December 2017). Response was defined as 50% improvement on validated rating scales. We extracted response rates from studies and imputed the missing ones with a validated method. Data were pooled in a single-group meta-analysis. Additionally, several potential moderators of response to antidepressants were examined by subgroup and meta-regression analyses.

RESULTS

We included 44 studies with a total of 6373 participants receiving antidepressants. On average, 50.7% of the patients reached a reduction of at least 50% on the Hamilton Depression Scale (HAMD). Subgroup and meta-regression analyses revealed a better response to treatment for patients in antidepressant-controlled trials compared to placebo-controlled trials. Mean age, study duration, percentage of woman, severity of illness at baseline, dose of antidepressants in fluoxetine equivalents, year of publication, setting (in- or out-patients), antidepressant groups (SSRI, TCA, SSNRI, α2-antagonist, SNRI, MAO-inhibitor), ITT (intention-to-treat) analysis vs completer analysis, sponsorship and overall risk of bias were not significant moderators of response.

CONCLUSIONS

Our findings suggest an improvement in symptoms can be found in about 50% of the elderly with major depressive disorder treated with antidepressants.

CA, Kasper S. Prognosis and improved outcomes in major depression: a review

Treatment outcomes for major depressive disorder (MDD) need to be improved. Presently, no clinically relevant tools have been established for stratifying subgroups or predicting outcomes. This literature review sought to investigate factors closely linked to outcome and summarize existing and novel strategies for improvement. The results show that early recognition and treatment are crucial, as duration of untreated depression correlates with worse outcomes. Early improvement is associated with response and remission, while comorbidities prolong course of illness. Potential biomarkers have been explored, including hippocampal volumes, neuronal activity of the anterior cingulate cortex, and levels of brain-derived neurotrophic factor (BDNF) and central and peripheral inflammatory markers (e.g., translocator protein (TSPO), interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor alpha (TNFα)). However, their integration into routine clinical care has not yet been fully elucidated, and more research is needed in this regard. Genetic findings suggest that testing for CYP450 isoenzyme activity may improve treatment outcomes. Strategies such as managing risk factors, improving clinical trial methodology, and designing structured step-by-step treatments are also beneficial. Finally, drawing on existing guidelines, we outline a sequential treatment optimization paradigm for selecting first-, second-, and third-line treatments for acute and chronically ill patients. Well-established treatments such as electroconvulsive therapy (ECT) are clinically relevant for treatment-resistant populations, and novel transcranial stimulation methods such as theta-burst stimulation (TBS) and magnetic seizure therapy (MST) have shown promising results. Novel rapid-acting antidepressants, such as ketamine, may also constitute a paradigm shift in treatment optimization for MDD.

Physical comorbidities in older adults receiving antidepressants in Asia

BACKGROUND

The present study explored the patterns of physical comorbidities and their associated demographic and clinical factors in older psychiatric patients prescribed with antidepressants in Asia.

METHODS

Demographic and clinical information of 955 older adults were extracted from the database of the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) project. Standardized data collection procedure was used to record demographic and clinical data.

RESULTS

Proportion of physical comorbidities in this cohort was 44%. Multiple logistic regression analyses showed that older age (OR = 1.7, P < 0.001), higher number of depressive symptoms (OR = 1.09, P = 0.016), being treated in psychiatric hospital (OR = 0.5, P = 0.002), living in high income countries/territories (OR = 2.4, P = 0.002), use of benzodiazepines (OR = 1.4, P = 0.013) and diagnosis of 'other psychiatric disorders' (except mood, anxiety disorders and schizophrenia) (OR = 2.7, P < 0.001) were significantly associated with physical comorbidities.

CONCLUSIONS

Physical comorbidities in older patients prescribed with antidepressants were common in Asia. Integrating physical care into the treatment of older psychiatric patients should be urgently considered.

Hospitalisation and surgery: Is exposure associated with increased subsequent depressive symptoms? Evidence from The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

The dramatic shift in the global population demographic has led to increasing numbers of older people undergoing hospitalisation and surgical procedures. While necessary, these exposures may lead to an increase in depressive symptoms.

OBJECTIVES

To determine whether hospitalisation or hospitalisation with surgery under general anaesthesia is associated with an increase in depressive symptoms in adults over the age of 50.

METHODS

Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale in 8036 individuals at waves 1 and 2 of The Irish Longitudinal Study on Ageing (TILDA), 2 years apart. Mixed-effects models were used to investigate the hypothesis after adjustment for risk factors for depression and potential confounders.

RESULTS

During the 12 months preceding wave 1, a total of 459 participants were hospitalised (mean age, 67.0; 55.3% female), and a further 548 participants (mean age, 64.6; 51.8% female) were hospitalised and underwent surgery with general anaesthesia; 6891 (mean age, 63.5; 54.3% female) were not hospitalised. Analysis of waves 1 and 2 data using mixed-effects models demonstrated that there was a 7% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.07 [1.02-1.11]) in the Center for Epidemiologic Studies Depression Scale in the hospitalisation group and a 4% increased adjusted incidence rate of depressive symptoms (IRR [95% CI] = 1.04 [1.00-1.08]) in the surgery group compared with those with no hospitalisation.

CONCLUSION

Hospitalisation and hospitalisation with surgery and general anaesthesia are associated with increased depressive symptoms. This is the first time a longitudinal population-representative study has demonstrated this relationship for both exposures simultaneously.

Geriatric characteristics in randomised controlled trials on antidepressant drugs for older adults: a systematic review

OBJECTIVE

Meta-analyses of antidepressant drug treatment trials have found that increasing age is associated with a less favourable outcome. Because the prevalence of geriatric characteristics, like disability, medical co-morbidity, malnutrition, cognitive (dys)function and frailty increase with age and are associated with depression, these characteristics are likely to modify the treatment outcome of antidepressant drugs in late-life depression. This review examines how these five characteristics are taken into account in randomised controlled trials (RCTs) with antidepressant drugs for major depressive disorder in patients aged 60 years or above.

DESIGN

A systematic search in PubMED, PsychInfo and EMBASE, from the year 2000 onwards, yielded 27 RCTs, with a total of 6356 subjects with a median age of 71 years. Two reviewers independently assessed whether each characteristic was considered as inclusion or exclusion criterion, descriptive variable, stratification variable, co-variable, outcome measure, or in adverse effect monitoring.

RESULTS

Malnutrition and frailty were not taken into account in any study. Disability was used as an outcome measure in five studies. Two studies explicitly included a population with possibly serious medical co-morbidity. Cognitive status was the only condition taken into account as co-variable (n = 3) or stratifying variable (n = 1) and was used as outcome measure in seven studies.

CONCLUSIONS

We conclude that geriatric characteristics are rarely taken into account in RCTs on antidepressant drugs in late-life depression, and studies including the oldest adults are underrepresented. This warrants recruitment of the oldest adults and adjustment of treatment strategies in future studies. Copyright © 2016 John Wiley & Sons, Ltd.

Determinants of Treatment-Resistant Depression: The Salience of Benzodiazepines

Treatment-resistant depression (TRD) lacks consensus regarding its definition, despite being common in clinical practice. This study was designed to identify factors contributing to TRD in patients diagnosed with a major depressive disorder. Patients were grouped into "low," "medium," and "high" treatment-resistant (TR) groups based on the number of medications that had been prescribed for their depression. We identified a number of factors linked to TRD. The high TR group was generally older, had a longer depressive episode duration, a higher number of comorbid medical and anxiety disorders, a lower education, and were less likely to be in full-time employment. They also reported less trait irritability and were more likely to view medication as being a contributor to their current depression. Some differences between non-melancholic and melancholic subsets were evident and point to the benefits in research on TRD analyzing the two diagnostic groups separately. The most striking finding was benzodiazepine use, which was significantly more common in the high TR group and within both the melancholic and non-melancholic subsets. Some potential explanations for this finding are offered.

Pharmacological approaches to manage persistent symptoms of major depressive disorder: rationale and therapeutic strategies

Major depressive disorder (MDD) is a highly prevalent chronic psychiatric illness associated with significant morbidity, mortality, loss of productivity, and diminished quality of life. Typically, only a minority of patients responds to treatment and meet criteria for remission as residual symptoms may persist, the result of an inadequate course of treatment and/or the presence of persistent side effects. The foremost goal of treatment should be to restore patients to full functioning and eliminate or relieve all MDD symptoms, while being virtually free of troublesome side effects. The current available pharmacological options to manage persistent depressive symptoms include augmentation or adjunctive combination strategies, both of which target selected psychobiological systems and specific mood and somatic symptoms experienced by the patient. As well, non-pharmacological interventions including psychotherapies may be used in either first-line or adjunctive approaches. However, the evidence to date with respect to available adjunct therapies is limited by few studies and those published have utilized only a small number of subjects and lack enough data to allow for a consensus of expert opinion. This underlines the need for further longer term, large population-based studies and those that include comorbid populations, all of which are seen in real world community psychiatry.

Association between skin conditions and depressive disorders in community-dwelling older adults

BACKGROUND

Depression is frequently observed in dermatologic patients. However, the association between depressive disorders and skin conditions has rarely been explored through population-based studies, especially within older-adult populations.

OBJECTIVE

To test this association in a representative sample of an older-adult population.

METHODS

Data came from the Survey on the Health of the Elderly (Enquête sur la Santé des Aìnés [ESA]), a longitudinal survey conducted in Quebec among 2,811 older adults. Cross-lagged panel models were used to simultaneously examine cross-sectional and longitudinal relationships between the presence of skin conditions and depressive disorders.

RESULTS

The prevalence of skin conditions was 13%, and the prevalence of depressive disorders among participants presenting with skin conditions was 11%. Our results indicated significant cross-sectional correlation (ζ  =  0.20) between skin conditions and depressive disorders, but no longitudinal association was observed.

CONCLUSION

Our results reinforce the hypothesis that skin conditions and depressive disorders are concurrently associated in older adults. However, no evidence of the predictive effect of skin problems on depression (and vice versa) was found in our community sample. Despite the deleterious effect of the coexistence of these problems in older adults, studies are lacking. This article highlights the importance of this issue and emphasizes the need for further research on this topic.

Does pain mediate or moderate the relationship between physical activity and depressive symptoms in older people? Findings from The Irish Longitudinal Study on Ageing (TILDA)

Background. Depression is an increasing problem in older adults, which is exacerbated by under diagnosis and ineffective treatment options. Broadly speaking, as people age, their levels of regular physical activity (PA) decrease, while their experience of chronic pain increases. PA has been shown to be an effective, yet under-utilised, treatment for depression in this age-cohort although the influence of pain on the relationship between PA and depressive symptoms has not been considered. Methods. Secondary analysis of national data from The Irish Longitudinal Study on Ageing (TILDA, 2011) (n = 8163 participants aged 50 years and older) examined the mediating or moderating role of pain in the relationship between depressive symptoms and PA, and the impact of PA, pain and depressive symptoms on health-care utilisation. Results. Approximately 8.5% TILDA older adults were depressed. No mediating or moderating effects of pain were found in the association between PA and depressive symptoms. Higher levels of PA were found to be independently associated with lower depressive symptoms, while higher levels of pain significantly increased the likelihood of depressive symptoms supporting previous findings. Depressive symptoms and higher levels of pain were also found to significantly increase health-care utilisation. Conclusions. Consistent with previous findings in this field, both PA and pain were found to be independently associated with depressive symptoms in Irish older adults. Furthermore, pain does not play a mediating or moderating role in the relationship between PA and depressive symptoms. Continued support for ongoing initiatives in this area aimed at increasing PA in older adults as a means to improve both physical and mental well-being is advised. The absence of any synergistic effect between PA and pain suggests that clinicians and health service providers should continue to promote PA as a treatment for depression, irrespective of the pain levels of their patients.

A longitudinal study of depression in old age II: depression and physical disability

Objectives: As part of an outcome study of depression in older people, the relationship between physical disability and depression was explored at baseline and longitudinally. The aims were to identify whether illness in specific body systems or physical disability was associated with a poorer outcome of depression.

Method: Subjects over 65 with depression referred to an old age psychiatry service were recruited. Depression was diagnosed according to ICD-10 criteria. An in-depth initial assessment obtained data concerning depression severity and illness in specific body systems as well as disability levels. Objective and subjective ratings of health status were also made. Subjects were followed up at three, six, 12, 18, and 24 months. Ongoing assessments were made of depressive symptomatology and of physical status.

Results: Subjects with higher disability levels had more severe depression at baseline. There was no relationship between illness in specific body systems and depression severity. At follow up assessments, those with higher disability scores had poorer outcomes as recorded by depression rating scales and by reviewing the longitudinal course of depression in terms of proportions remaining well, suffering relapses or remaining depressed.

Conclusions: There is an ongoing relationship between depression and disability. Older people with greater physical disability have a poorer outcome of depression. Service providers should be aware of this relationship and respond rapidly and assertively to depression in older people with disability. There should be a lower threshold for initiating treatment in this population.

Physical co-morbidity among treatment resistant vs. treatment responsive patients with major depressive disorder

Co-morbid physical illness has been suggested to play an important role among the factors contributing to treatment resistance in patients with major depressive disorder. In the current study we compared the rate of physical co-morbidity, defined by ICD-10, among a large multicenter sample of 702 patients with major depressive disorder. A total of 356 of the participants were defined as treatment resistant depression (TRD) patients-having failed two or more adequate antidepressant trials. No significant difference was found between TRD and non-TRD participants in the prevalence of any ICD-10 category. This finding suggests that although physical conditions such as diabetes, thyroid dysfunction, hypertension, ischemic heart disease, and peptic diseases are often accompanied by co-morbid MDD, they do not necessarily have an impact on the course of MDD or the likelihood to respond to treatment. Marginally higher rates of co-morbid breast cancer, migraine and glaucoma were found among TRD participants. Possible explanations for these findings and their possible relation to TRD are discussed.

Factors associated with non-completion in a double-blind randomized controlled trial of olanzapine plus sertraline versus olanzapine plus placebo for psychotic depression

High rates of attrition have been reported in randomized controlled trials of patients with severe psychiatric illness, including psychotic depression (MDpsy). The purpose of this study is to examine factors associated with overall attrition and with subtypes of attrition in the Study of the Pharmacotherapy of Psychotic Depression (STOP-PD). Secondary analysis of data collected in a multi-site, randomized, placebo-controlled trial. Clinical services of academic hospitals. Participants comprised 259 persons with MDpsy, aged 18-93 years. The intervention consisted of the random allocation to 12 weeks of treatment of either olanzapine plus sertraline or olanzapine plus placebo. Demographic and clinical variables associated with overall non-completion and sub-types of non-completion of randomized treatment. One hundred and seventeen (45.2%) subjects did not complete 12 weeks of randomized treatment. In a logistic regression analysis, inpatient entry status, olanzapine monotherapy, and higher cumulative medical burden were statistically significant independent predictors of overall non-completion. In a multinomial logistic regression model that examined predictors of subtypes of non-completion, subjects who entered the study as an inpatient were less likely to complete because of inadequate efficacy as determined by the investigator, and older subjects were less likely to complete because of poorer tolerability. Subjects who were assigned to olanzapine monotherapy, younger subjects, and subjects who entered the study as inpatients were less likely to complete because of reasons other than efficacy or tolerability. Understanding factors that contribute to premature discontinuation in studies of MDpsy, and to the specific reasons for attrition, has the potential to improve the management of this disorder, as well as improve the design of future clinical trials of MDpsy.

Physical comorbidity and 12-week treatment outcomes in Korean patients with depressive disorders: the CRESCEND study

OBJECTIVE

Physical and depressive disorders frequently co-occur, but effects of physical health on depression treatment outcomes have received little research. This study aimed to compare treatment outcomes between people with depressive disorder with and without comorbid physical disorders.

METHODS

A Korean nationwide sample of 723 people with depressive disorder initiated on antidepressant treatment, and re-evaluated at 1, 2, 4, 8, and 12 weeks later. Assessment scales for evaluating depressive symptoms (HAMD), anxiety (HAMA), global severity (CGI-s), and functioning (SOFAS) were administered at baseline and every follow-up visit. Achievement of remission or response was defined only when these were maintained to the 12 weeks study endpoint or to the last follow-up examination, if earlier, with the date of the first observed remission point applied as the timing of remission. Logistic regression and Cox proportional hazards models were used.

RESULTS

Of the sample, 247 (34%) had at least one physical disorder. This was associated with lower socioeconomic status and more severe depressive symptoms at baseline, but was not associated with any treatment related characteristics including antidepressant type and regimen, concomitant medications, side effects, and duration of treatment period. After adjustment, patients with physical comorbidity responded more slowly and less often - particularly in domains of anxiety, global severity, and functioning (all p-values <.005).

CONCLUSION

More intensive assessment and integrated treatment approaches are needed to facilitate treatment responses for depressive disorders in people with physical comorbidity. Future comparative studies between conventional and integrated treatment approaches are indicated for depressive disorders with physical comorbidity.

Treating post-CABG depression with telephone-delivered collaborative care: does patient age affect treatment and outcome?

OBJECTIVE

To determine the nature of telephone-delivered collaborative care intervention provided to patients younger than and older than 60 years experiencing clinically significant depressive symptoms after coronary artery bypass graft (CABG) surgery and whether patient age is related to response and remission rates and delivery of care at 8-month follow-up.

DESIGN

: Exploratory post-hoc analysis of data collected in a randomized controlled trial (RCT).

SETTING

Seven Pittsburgh-area general hospitals.

PARTICIPANTS

Fifty-eight depressed post-CABG patients younger than 60 and 92 comparable patients age 60 years and older randomized to the RCT's intervention arm.

MEASUREMENTS

: Components of collaborative care provided to patients over the 8-month study period and Hamilton Rating Scale for Depression scores at 8-month follow-up to determine response and remission status.

RESULTS

There were no differences in the cumulative 8-month rates at which the components of collaborative care were delivered to the two age groups. Similar response and remission rates were also achieved by these groups.

CONCLUSION

Older and younger patients experiencing clinical depression after CABG surgery can be treated with comparable components of collaborative care, and both age groups will achieve clinical outcomes that do not differ significantly from each other.

Remission in major depression: results from a geriatric primary care population

OBJECTIVES

While a recent task force report recommended that remission from major depression be defined according to DSM criteria, most previous work has used depressive symptom rating scales. The current study sought to identify baseline factors associated with treatment outcome in major depression, diagnosed according to DSM-IV criteria.

METHODS

Data from the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study were utilized. This analysis focused on 792 geriatric primary care patients with major depression at baseline, which was randomized to services by a mental health professional in primary care or specialty settings. Major depression was diagnosed according to DSM-IV criteria based on a structured interview at baseline and 6 months. The primary outcome was the absence of any DSM-IV depressive disorder at six-month follow-up. Association with baseline demographic characteristics, comorbid anxiety disorder, 'at risk' drinking, number of co-occurring medical conditions, and depressive symptom severity was examined using multiple logistic regression modeling.

RESULTS

Remission occurred in 228 (29%) patients with completed follow-up assessments, while 564 (71%) did not remit. Factors which increased the odds of non-remission included comorbid anxiety (OR=1.60, 95% CI 1.11-2.31), female sex (OR=1.49, 95% CI 1.04-2.15), general medical comorbidity (OR=1.15, 95% CI 1.07-1.24), and increased baseline depressive symptom severity (OR=1.04, 95% CI 1.03-1.06).

CONCLUSIONS

The findings underscore the importance of using DSM criteria to define remission from major depression, and suggest that concurrent measurement of depression severity, comorbid anxiety, and medical comorbidity are important in identifying patients requiring targeted interventions to optimize remission from major depression.

The impact of diabetes on depression treatment outcomes

BACKGROUND

Individuals with diabetes mellitus (DM) are two to four times more likely to be diagnosed with major depressive disorder (MDD). However, few controlled studies have examined the impact of DM on the treatment of MDD. Understanding the effect of DM on depressed patients could provide valuable clinical information toward adjusting current treatment modalities to produce a more effective treatment for depressed patients with DM.

METHODS

This study was conducted using an evaluable sample of 2876 outpatient participants enrolled in the Sequenced Treatment Alternatives to Relieve Depression study. Sociodemographic and clinical characteristics and treatment characteristics with the selective serotonin reuptake inhibitor (SSRI) citalopram, as well as remission rates for MDD and time to remission, were compared between participants with DM and participants without DM.

RESULTS

The odds of remission were lower in participants with DM than in those without DM prior to adjustment [odds ratio (OR)=0.68; 95% confidence interval (95% CI)=(0.49, 0.94); P=.0184]. These differences were no longer present after adjustment [OR=0.92; 95% CI=(0.64, 1.32); P=.6399]. Participants with DM reported fewer side effects than participants without DM despite similar dosing.

CONCLUSIONS

Depressed patients with DM and depressed patients without DM appear to have similar rates of MDD remission, indicating that a diagnosis of DM per se has no impact on MDD remission. The findings of fewer side effects and psychiatric serious adverse events in participants with DM imply that depressed patients with DM may be excellent candidates for more aggressive SSRI dosing. This lower prevalence of side effects reported by depressed participants with DM warrants further exploration.

Duloxetine for the treatment of recurrent major depressive disorder in elderly patients: treatment outcomes in patients with comorbid arthritis

BACKGROUND

Evaluation and treatment of major depression (MDD) in elderly patients is frequently complicated by the presence of comorbid medical conditions, which can reduce the effect of depression treatment, leading to lower rates of depressive-symptom improvement and higher rates of relapse.

OBJECTIVE

The authors investigated results of antidepressant concurrent with arthritis pain treatment in elderly patients.

METHOD

Patients age 65 and over with recurrent MDD were stratified by arthritis status and randomized to duloxetine (a dual reuptake-inhibitor of serotonin and norepinephrine) or placebo treatment for 8 weeks (duloxetine, N=117; placebo, N=55).

RESULTS

Duloxetine significantly reduced MDD symptom severity in elderly patients with and without arthritis, and produced significant reduction in several pain measures in those patients with comorbid arthritis.

DISCUSSION

The magnitude and time-course of depressive symptom improvement did not differ significantly between patients with and without arthritis. Some studies have suggested that the severity of pain in arthritis patients may be linked to depression severity.

Incomplete response in late-life depression: getting to remission

Incomplete response in the treatmen tof late-life depression is a large public health challenge: at least 50% of older people fail to respond adequately to first-line antidepressant pharmacotherapy, even under optimal treatment conditions. Treatment-resistant late-life depression (TRLLD) increases risk for early relapse, undermines adherence to treatment for coexisting medical disorders, amplifies disability and cognitive impairment, imposes greater burden on family caregivers, and increases the risk for early mortality, including suicide, Gettinq to and sustaininq remission is the primary goal of treatment yet there is a paucity of empirical data on how best to manage TRLLD. A pilot study by our group on aripiprazole augmentation in 24 incomplete responders to sequential SSRI and SRNI pharmacotherapy found that 50% remitted over 12 weeks with the addition of aripiprazole, and that remission was sustained in all participants during 6 months of continuation treatment In addition to controlled assessment, evidence is needed to support personalized treatment by testing the moderating role of clinical (eg, comorbid anxiety, medical burden, and executive impairment) and genetic (eg, selected polymorphisms in serotonin, norepinephrine, and dopamine genes) variables, while also controlling for variability in drug exposure. Such studies may advance us toward the goal of personalized treatment in late-life depression.

Mental disorders among persons with arthritis: results from the World Mental Health Surveys

BACKGROUND

Prior studies in the USA have reported higher rates of mental disorders among persons with arthritis but no cross-national studies have been conducted. In this study the prevalence of specific mental disorders among persons with arthritis was estimated and their association with arthritis across diverse countries assessed.

METHOD

The study was a series of cross-sectional population sample surveys. Eighteen population surveys of household-residing adults were carried out in 17 countries in different regions of the world. Most were carried out between 2001 and 2002, but others were completed as late as 2007. Mental disorders were assessed with the World Health Organization (WHO) World Mental Health-Composite International Diagnostic Interview (WMH-CIDI). Arthritis was ascertained by self-report. The association of anxiety disorders, mood disorders and alcohol use disorders with arthritis was assessed, controlling for age and sex. Prevalence rates for specific mental disorders among persons with and without arthritis were calculated and odds ratios (ORs) with 95% confidence intervals were used to estimate the association.

RESULTS

After adjusting for age and sex, specific mood and anxiety disorders occurred among persons with arthritis at higher rates than among persons without arthritis. Alcohol abuse/dependence showed a weaker and less consistent association with arthritis. The pooled estimates of the age- and sex-adjusted ORs were about 1.9 for mood disorders and for anxiety disorders and about 1.5 for alcohol abuse/dependence among persons with versus without arthritis. The pattern of association between specific mood and anxiety disorders and arthritis was similar across countries.

CONCLUSIONS

Mood and anxiety disorders occur with greater frequency among persons with arthritis than those without arthritis across diverse countries. The strength of association of specific mood and anxiety disorders with arthritis was generally consistent across disorders and across countries.

Serious life events among resistant and non-resistant MDD patients

BACKGROUND

Over 60% of patients with major depressive disorder (MDD) do not respond fully to therapy. Half of them eventually will not respond at all and will be referred to as treatment resistant depression (TRD) patients. Stressful life events were found to be associated with MDD and were also found to affect the course of the disease. We hypothesize that negative life events might be an independent risk factor for TRD.

METHODS

One hundred and seven unipolar MDD patients, all treated for at least 4 weeks, were enrolled in the study. Patients were assessed on their psychiatric and medical history, and seven categories of stressful life events.

RESULTS

39.3% of participants were defined as TRD patients and 60.7% as non-TRD. TRD patients had more severe depression, more past suicide attempts, more hospitalizations, longer episodes, and received more benzodiazepines, antipsychotics, and ECT. Job loss and financial stress were more prevalent among the TRD group. Overall, the TRD patients had more negative life events than responders.

LIMITATIONS

This is a retrospective study. In addition, the definition of TRD was done dichotomically, therefore the association between number of stressful life events and the degree of resistance was not tested.

CONCLUSIONS

Job loss and financial distress were found to predict TRD. The loss of a parent and severe health conditions were not associated with TRD, suggesting that events affecting the development of MDD, do not necessarily affect the treatment outcome.

Frontal white matter anisotropy and antidepressant remission in late-life depression

Introduction

Neuroanatomic features associated with antidepressant treatment outcomes in older depressed individuals are not well established. This study used diffusion tensor imaging to examine frontal white matter structure in depressed subjects undergoing a 12-week trial of sertraline. We hypothesized that remission would be associated with higher frontal anisotropy measures, and failure to remit with lower anisotropy.

Methods

74 subjects with Major Depressive Disorder and age 60 years or older were enrolled in a twelve-week open-label trial of sertraline and completed clinical assessments and 1.5T magnetic resonance brain imaging. The apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were measured in regions of interest placed in the white matter of the dorsolateral prefrontal cortex, anterior cingulate cortex, and corpus callosum. Differences in ADC and FA values between subjects who did and did not remit to treatment over the study period were assessed using generalized estimating equations, controlling for age, sex, medical comorbidity and baseline depression severity.

Results

Subjects who did not remit to sertraline exhibited higher FA values in the superior frontal gyri and anterior cingulate cortices bilaterally. There were no statistically significant associations between ADC measures and remission.

Conclusions

Failure to remit to sertraline is associated with higher frontal FA values. Functional imaging studies demonstrate that depression is characterized by functional disconnection between frontal and limbic regions. Those individuals where this disconnection is related to structural changes as detected by DTI may be more likely to respond to antidepressants.

Trial Registration

ClinicalTrials.gov NCT00339066

The quality of medical care for comorbid conditions of depressed elders

OBJECTIVES

In light of large variation in the quality of medical care, this study assesses the extent to which medical care for depressed elders is consistent with systematic quality standards.

METHOD

Using the Donabedian model, we assess factors related to two quality measures: medical service fit and medical provider contact. We assessed 110 depressed older adults with comorbid conditions through practical guidelines of medical services.

RESULTS

We found large variation in the quality of medical care and differences between two quality measures. Structure (Medigap insurance and clinical factors) and process factors (medical professional visits, ER visits, and adequacy of informal care) influenced the quality of medical care.

CONCLUSION

Emphasizing accuracy in quality measures, quality disparities by medical conditions call attention to the risky population with certain conditions targeted for closer follow-up. Appropriate medical care processes can enhance the quality.

The impact of depressive symptoms and chronic diseases on active life expectancy in older Americans

OBJECTIVES

The authors prospectively examined whether depressive symptoms (DS) in older adults negatively affected active live expectancy (ALE), or remaining years free of disability, and mortality, independently and in the presence of chronic diseases, and after stratification by gender.

DESIGN

Prospective cohort study, first three waves (1993-1998) of the Asset and Health Dynamics Among the Oldest Old.

DATA COLLECTION

University of Michigan; analysis: University of South Florida.

PARTICIPANTS

Nationally representative sample of community-dwelling adults age 70 and older (N = 7,381).

MEASUREMENTS

DS (Center for Epidemiological Studies Depression, 8-item version), self-reported cancer, diabetes, heart disease, or stroke, difficulty with activities of daily living, death, and estimates of total, active, and disabled life expectancy.

RESULTS

DS reduced ALE by 6.5 years for young-old men (age 70), 3.2 years for old-old men (age 85), 4.2 years for young-old women, and 2.2 years for old-old women, and these effects remained significant at all ages and across gender even after controlling for chronic disease, the one exception being DS and cancer in old-old women. DS also reduced total life expectancy significantly, although controlling for some chronic diseases (particularly cancer and stroke) eliminated the effect of DS across age and gender groups.

CONCLUSION

Depressive symptoms represent a serious and distinct threat to independent functioning in older adults. Whether experienced alone, or in combination with chronic diseases, depressive symptoms shorten ALE substantially. Timely diagnosis and treatment of depressive symptoms in older adults may delay the onset of disability and improve the quality of life.

A comparison of baseline sociodemographic and clinical characteristics between major depressive disorder patients with and without diabetes: a STAR*D report

BACKGROUND

Patients with major depressive disorder (MDD) have high rates of medical comorbidities which can impair MDD treatment. Yet little is known regarding associations between the presence of a serious comorbidity and MDD treatment. The purpose of this study was to examine the baseline sociodemographic and clinical characteristics of MDD outpatients with and without diabetes mellitus to evaluate possible associations between these characteristics and the presence of comorbid diabetes.

METHODS

We gathered baseline sociodemographic and clinical data for 4041 participants with non-psychotic MDD who enrolled in the STAR*D, a large-scale depression treatment protocol, and made comparisons between participants with and without diabetes.

RESULTS

Participants with diabetes were more likely to be male, older, black, Hispanic, unemployed, and have less education, a lower income, higher mental functioning, lower physical functioning, atypical features, increased appetite, psychomotor slowing and leaden paralysis, and were less likely to have concurrent alcohol abuse/dependence, mood reactivity or problems with concentration. We found no significant differences between groups regarding depression severity.

LIMITATIONS

The primary limitation is the lack of a clinical diagnosis of diabetes.

CONCLUSIONS

We found no difference in depression severity between participants with and without diabetes. Diabetes was associated with physical symptoms of depression. Thus treatments for these participants should be directed toward these symptoms.

Psychiatric comorbidity and greater hospitalization risk, longer length of stay, and higher hospitalization costs in older adults with heart failure

OBJECTIVES

To explore associations between psychiatric comorbidity and rehospitalization risk, length of hospitalization, and costs.

DESIGN

Cross-sectional study of 1-year hospital administrative data.

SETTING

Claims-based study of older adults hospitalized in the United States.

PARTICIPANTS

Twenty-one thousand four hundred twenty-nine patients from a 5% national random sample of U.S. Medicare beneficiaries aged 65 and older, with at least one acute care hospitalization in 1999 with a Diagnostic-Related Group of congestive heart failure.

MEASUREMENTS

The number of hospitalizations, mean length of hospital stay, and total hospitalization costs in calendar year 1999.

RESULTS

Overall, 15.8% of patients hospitalized for heart failure (HF) had a coded psychiatric comorbidity; the most commonly coded comorbid psychiatric disorder was depression (8.5% of the sample). Most forms of psychiatric comorbidity were associated with greater inpatient utilization, including risk of additional hospitalizations, days of stay, and hospitalization charges. Additional hospitalization costs associated with psychiatric comorbidity ranged up to $7,763, and additional days length of stay ranged up to 1.4 days.

CONCLUSION

Psychiatric comorbidity appears in a significant minority of patients hospitalized for HF and may affect their clinical and economic outcomes. The associations between psychiatric comorbidity and use of inpatient care are likely to be an underestimate, because psychiatric illness is known to be underdetected in older adults and in hospitalized medical patients.

Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions

BACKGROUND

Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment.

OBJECTIVE

To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD).

DESIGN

Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients.

PARTICIPANTS

Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states.

MEASUREMENTS

The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen > or = 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics.

RESULTS

Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity.

CONCLUSIONS

PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.

Treating depression in the medically ill

Depression frequently is comorbid with a variety of medical illnesses; individuals who have such comorbidities may have increased morbidity and lower functional status. Usual antidepressant treatments can be effective in depressed patients who have comorbid medical illness. These patients, however, experience lower rates of recovery and remission of depressive symptoms and higher rates of relapse during follow-up than seen in patients who have MDD with no medical comorbidity. Comorbid medical illness therefore is a marker of treatment resistance in MDD. Collaborative treatments combining antidepressants, psychotherapy, education, and case management may be effective and could overcome the risk of treatment resistance. Two clinical strategies seem warranted in light of the studies presented here: (1) an increased index of suspicion for depression in medically ill patients, and (2) more intensive antidepressant treatment in depressed patients who have medical comorbidity.

Differentiating antidepressants of the future: Efficacy and safety

There have been significant advances in the treatment of depression since the serendipitous discovery that modulating monoaminergic neurotransmission may be a pathological underpinning of the disease. Despite these advances, particularly over the last 15years with the introduction of selective serotonin and/or norepinephrine reuptake inhibitors (SNRI), there still remain multiple unmet clinical needs that would represent substantial improvements to current treatment regimens. In terms of efficacy there have been improvements in the percentage of patients achieving remission but this can still be dramatically improved and, in fact, issues still remain with relapse. Furthermore, advances are still required in terms of improving the onset of efficacy as well as addressing the large proportion of patients who remain treatment resistant. While this is not well understood, collective research in the area suggests the disease is heterogeneous in terms of the multiple parameters related to etiology, pathology and response to pharmacological agents. In addition to efficacy further therapeutic advances will also need to address such issues as cognitive impairment, pain, sexual dysfunction, nausea and emesis, weight gain and potential cardiovascular effects. With these unmet needs in mind, the next generation of antidepressants will need to differentiate themselves from the current array of therapeutics for depression. There are multiple strategies for addressing unmet needs that are currently being investigated. These range from combination monoaminergic approaches to subtype selective agents to novel targets that include mechanisms to modulate neuropeptides and excitatory amino acids (EAA). This review will discuss the many facets of differentiation and potential strategies for the development of novel antidepressants.

The relationship of medical comorbidity and depression in older, primary care patients

Comorbid medical illnesses are a key feature of geriatric mood disorders, yet the specificity of such associations remains unclear. In a sample of 546 primary care patients age >or=65 years, pathology in several organ systems (respiratory, eye/ear/nose/throat, gastrointestinal, central nervous system, endocrine) and several chronic conditions (neurological disease, low vision, chronic obstructive pulmonary disease, diabetes) were associated with depression. However, notwithstanding these specific associations, global (overall) medical burden was most powerfully and independently associated with depression, largely independent of functional status. This generates the hypothesis that, in general primary care populations, the relationship of medical illness to depression may be multimodal and/or may involve shared pathobiological or psychosocial mechanisms.

The role of medical comorbidity in outcome of major depression in primary care: the PROSPECT study

OBJECTIVE

The authors described the influence of specific medical conditions on clinical remission and response of major depression (MDD) in a clinical trial evaluating a care-management intervention among older primary-care patients.

METHODS

Adults age 60 years and older were randomly selected and screened for depression. Participants were randomly assigned to Usual Care or to an Intervention with a depression care-manager offering algorithm-based care for MDD. In all, 324 adults meeting criteria for MDD were included in these analyses. Remission and response was defined by a score on the Hamilton Rating Scale for Depression <10 and by a decrease from baseline of > or =50%, respectively. Medical comorbidity was ascertained through self-report. Cognitive impairment was defined by a score <24 on the Mini-Mental State Exam (MMSE).

RESULTS

In Usual Care, rates of remission were faster in persons who reported atrial fibrillation (AF) than in persons who did not report AF and slower in persons who reported chronic pulmonary disease than in persons who did not report chronic pulmonary disease; rates of response were less stable in persons with MMSE <24 than in those with MMSE > or =24. In the Intervention condition, none of the specific chronic medical conditions were significantly associated with outcomes for MDD.

CONCLUSIONS

Because disease-specific findings were observed in persons who received Usual Care but not in persons who received more intensive treatment in the Intervention condition, our results suggest that the association of medical comorbidity and treatment outcomes for MDD may be determined by the intensity of treatment for depression.

Medical illness and response to treatment in primary care panic disorder

OBJECTIVE

Although studies have suggested that comorbid medical illness can affect the outcome of patients with depression, little is known about whether medical illness comorbidity affects treatment outcome in patients with anxiety.

METHOD

Primary care patients with panic disorder (n=232), participating in a randomized collaborative care intervention of CBT and pharmacology, were divided into those above (n=125) and below (n=107) the median for burden of chronic medical illness and assessed at 3, 6, 9 and 12 months.

RESULTS

Subjects with a greater burden of medical illness were more psychiatrically ill at baseline, with greater anxiety symptom severity, greater disability and more psychiatric comorbidity. The intervention produced significant and similar increases in amount of evidence-based care, and reductions in clinical symptoms and disability that were comparable in the more and less medically ill groups.

CONCLUSIONS

The comparable response of individuals with more severe medical illness suggests that CBT and pharmacotherapy for panic disorder work equally well regardless of medical illness comorbidity. However, the more severe psychiatric illness both at baseline and follow-up in these same individuals suggest that treatment programs may need to be extended in time to optimize treatment outcome.

Factors associated with chronic illness among the elderly in a rural community in Malaysia

Chronic illness is one of the major causes of mortality and morbidity among the elderly. To determine the prevalence and factors associated with chronic illness among the elderly in a rural community setting. A cross sectional study design was used. Stratified proportionate cluster sampling method was used to select respondents in Mukim Sepang, Sepang, Selangor, Malaysia. Out of 263 elderly residents (6.2% of the total population), 223 agreed to participate in the study giving a response rate of 84.8%. The prevalence of chronic illness among the elderly in Mukim Sepang was 60.1%. Out of 223 respondents, 134 were diagnosed as having chronic illness such as hypertension, diabetes mellitus, ischaemic heart disease, bronchial asthma or gout. Chronic illness was found to be significantly associated with functional dependence among the elderly (chi2=6.863, df=1, p<0.05). The prevalence of chronic illness among the elderly in the rural community is very high. Problems facing this age-group should be addressed comprehensively in order to formulate appropriate programmes for the health care of the elderly.

Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR*D

BACKGROUND

A significant percentage of patients with major depressive disorder (MDD) suffer from concurrent general medical conditions (GMCs).

OBJECTIVE

The objective of this preliminary report was to describe the rates of co-occurring significant GMCs and the clinical correlates and symptom features associated with the presence of GMCs.

DESIGN

Baseline cross-sectional case-control study of patients enrolling in a prospective randomized multistage treatment study of MDD.

SETTING

Fourteen regional U.S. centers representing 19 primary care and 22 psychiatric practices.

PATIENTS

One thousand five hundred outpatients with DSM-IV nonpsychotic MDD.

MEASUREMENTS

Sociodemographic status, medical illness ratings, psychiatric status, quality of life and DSM-IV depression symptom ratings.

RESULTS

The prevalence of significant medical comorbidity in this population was 52.8% (95% CI 50.3-55.3%). Concurrent significant medical comorbidity was associated with older age, lower income, unemployment, limited education, longer duration of index depressive episode and absence of self-reported family history of depression. Somatic symptoms common in MDD were endorsed at a higher rate in those with GMCs. Those without a GMC had higher rates of endorsement of impaired mood reactivity, distinct mood quality and interpersonal sensitivity.

CONCLUSIONS

Concurrent GMCs are common among outpatients with MDD in both primary care and specialty settings. Concurrent GMCs appear to influence the severity and symptom patterns in MDD and describe a vulnerable population with sociodemographic challenges to effective assessment and treatment.

Comorbid medical illness and relapse of major depressive disorder in the continuation phase of treatment

The authors examined the impact of comorbid medical illness on the rate of relapse of major depressive disorder during continuation therapy. Subjects (N = 128) with major depressive disorder (according to DSM-III-R criteria) achieved clinical remission (a 17-item Hamilton Depression Rating Scale score < or = 7) after 8 weeks of treatment with fluoxetine and entered the continuation phase of antidepressant treatment. They used the Cumulative Illness Rating Scale to measure the severity of comorbid medical illness. Eight patients (6.3%) relapsed during the 28-week continuation phase. With logistic regression, the total burden and the severity of comorbid medical illness significantly predicted the relapse of major depressive disorder during continuation therapy with fluoxetine. Greater medical comorbidity was also associated with higher increases in self-reported symptoms of depression, anxiety, and anger during the follow-up.

Impact of medical comorbid disease on antidepressant treatment of major depressive disorder

A major factor in evaluating and treating depression is the presence of comorbid medical problems. In this paper, the authors will first evaluate studies showing that medical illness is a risk factor for depression. The authors will review a series of randomized, controlled studies of antidepressant treatment in subjects with major depressive disorder (MDD) and comorbid medical illnesses (myocardial infarction, stroke, diabetes, cancer, and rheumatoid arthritis). Most of these studies report an advantage for an active antidepressant over placebo in improvement of depressive symptoms. The authors also will review a series of studies in which the outcome of antidepressant treatment is compared between subjects with MDD with and without comorbid medical illness. In these studies, subjects with medical illness tend to have lower improvement of depressive symptoms and higher rates of depressive relapse with antidepressant treatment compared with MDD subjects with no medical comorbidity. In addition, the authors will review hypotheses on the mechanism of the interaction between medical illness and clinical response in MDD. The paper will conclude that medical comorbidity is a predictor of treatment resistance in MDD.

Treatment patterns and outcomes of depressed medically ill and non-medically ill patients in community psychiatric practice

The prevalence of depression among the medically ill, the recognition of depression in general medical practice, and the association between depression and medical illness have all been a focus for research in recent years. Less is known about the process and outcomes of depression care in the medically ill compared with the non-medically ill, but some studies suggest that those with concomitant physical illness have poorer outcomes. In a study of community psychiatric practice, a sample of 53 patients with no medical comorbidity (NMI) was compared with 50 patients, categorized by higher (HMI) or lower (LMI) levels of physical comorbidity, approximately 5 months after beginning treatment for a current episode of major depression. No differences were found in treatments received or in mental health outcomes between the three groups. The HMI group showed greater impairment in social and occupational functioning at baseline and significantly greater improvement in these variables at follow-up. Since medical comorbidity does not appear to adversely affect treatment decisions or outcomes in community psychiatric practice, depressed, physically ill patients should be encouraged to seek treatment, regardless of their medical condition or level of disability.

Achieving long-term optimal outcomes in geriatric depression and anxiety

Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.