Which factors are important predictors of non-recovery from major depression? A 2-year prospective observational study

Predictors of poor 6-week outcome in a cohort of major depressive disorder patients treated with antidepressant medication: the role of entrapment

BACKGROUND

Only a small number of consistent processes predict which depressed patients will achieve remission with antidepressant medication. One set of processes is that of social ranking strategies/variables that are related to life events and severe difficulties. Particularly, defeat and entrapment predict poorer response to antidepressants. However, results are inconsistent.

AIM

The current study aimed to evaluate evolutionary strategies, childhood maltreatment, neglect and life events and difficulties (LEDs) as predictors of remission in depressed patients undergoing pharmacological treatment in a psychiatric outpatient sample.

METHODS

A cohort of 139 depressed outpatients undergoing pharmacological treatment was followed prospectively in a naturalistic study for 6 weeks. Two major evaluations were considered at baseline and 6 weeks. We allocated patients to a pharmacological treatment algorithm for depression - the Texas Medication Algorithm Project. Variables evaluated at baseline and tested as predictors of remission included demographic and clinical data, severity of depression, social ranking, evolution informed variables, LEDs and childhood maltreatment.

RESULTS

Of the 139 patients, only 24.5% were remitted at week 6. In univariate analyses, non-remitted patients scored significantly higher in all psychopathology and vulnerability scales except for submissive behaviour and internal entrapment. For the logistic regression, a higher load of LEDs of the entrapment and humiliation dimension in the year before the index episode (OR = 6.62), and higher levels external entrapment in the Entrapment Scale (OR = 1.10) predicted non-remission. These variables accounted for 28.7% of the variance.

CONCLUSIONS

Multivariate analysis revealed that external entrapment was the only predictor of non-remission.

Longterm persistence and nonrecurrence of depression treatment in Germany: a four-year retrospective follow-up using linked claims data

OBJECTIVES

To measure persistence and nonrecurrence of depression treatment and investigate potential risk factors.

METHODS

We retrospectively observed a closed cohort of insurees with new-onset depression treatment in 2007 and without most psychiatric comorbidity for 16 quarters (plus one to ascertain discontinuation). We linked inpatient/outpatient/drug-data per person and quarter. Person-quarters containing specified depression services were classified as depression-treatment-person-quarters (DTPQ). We defined longterm-DTPQ-persistence as 16 + 1 continuous DTPQ and longterm-DTPQ-nonrecurrence as 12 continuous quarters without DTPQ and used multivariate logistic regression to explore associations with these outcomes.

RESULTS

Within first 16 quarters, 28,348 patients' first period (total time) persisted for a mean/median 5.4/3 (8.7/8) quarters. Fourteen percent had longterm-DTPQ-persistence, associated (p < .05) with baseline hospital (odds ratio, OR = 1.80), psychotherapy/specialist-interview and antidepressants (OR = 1.81), age (years, OR = 1.03), unemployment (OR = 1.21), retirement (OR = 1.31), and insured as a dependent (OR = 1.32). Thirty-four percent had longterm-DTPQ-nonrecurrence, associated with psychotherapy/specialist-interview (OR = 1.40), antidepressants (OR = 0.54), female sex (OR = 0.84), age (years, OR = 0.99), retirement (OR = 1.18), and insured as a dependent (OR = 0.88). Women differed for episodic and not chronic treatment.

CONCLUSION

Treatment measures compared to survey's symptoms measures. We suggest further research on "treatment-free-time." Antidepressants(-) and psychotherapy/specialist-interview(+) were significantly associated with longterm-DTPQ-nonrecurrence. This was presumably moderated by possible short-time/low-dosage antidepressants use(-) and selective therapy assignment(+). Sample selectivity limited data misclassification.

The influence of thoughts of death and suicidal ideation on the course of depression in older depressed patients

OBJECTIVE

Thoughts of death are not regularly included in diagnostic instruments and rarely examined separately from thoughts of suicide. This exploratory study examined whether thoughts of death and thoughts of suicide affect the course of late-life depressive disorders.

METHODS

In 378 depressed older persons, thoughts of death and thoughts of suicide were assessed using questions from the Composite International Diagnostic Interview. After 2 years, the presence of a DSM-IV-TR diagnosis of minor or major depression or dysthymia was assessed with the Composite International Diagnostic Interview. The Inventory of Depressive Symptomatology was administered every 6 months up till 3-year follow-up.

RESULTS

Multinomial logistic regression showed that thoughts of death as well as thoughts of suicide predicted double depression at follow-up (OR = 2.14 [95% CI: 1.04-4.40] and OR = 6.47 [95% CI: 2.22-3.02], respectively), compared with patients without these thoughts. Results became non-significant when adjusted for baseline depression severity (OR = 1.17 [95% CI: 0.52-2.63] and OR = 2.57 [95% CI: 0.79-8.84], respectively). Mixed linear models showed that severity of depression was lowest in the reference group, while symptoms decreased more over time in those with either thoughts of death or suicide.

CONCLUSIONS

Patients with thoughts of death or with thoughts of suicide were more severely depressed at baseline and follow-up, with the highest risk of being depressed at follow-up for patients with thoughts of suicide. These associations could be explained by baseline depression severity. The results suggest that thoughts of death and thoughts of suicide are important risk markers in predicting the course of depression. Copyright © 2016 John Wiley & Sons, Ltd.

Recovery in patients with major depressive disorder (MDD): results of a 6-month, multinational, observational study

Not all individuals treated for major depressive disorder (MDD) achieve recovery. This observational study examined the recovery rates in MDD patients and the patient characteristics associated with achieving recovery in a naturalistic clinical setting. Recovery was defined as having both clinical and functional remission. Data for this post hoc analysis were taken from a 24-week prospective, observational study that involved 1,549 MDD patients. Clinical remission was assessed using the 16-item Quick Inventory of Depressive Symptomatology Self-Report and functional remission through the Sheehan Disability Scale and no days of reduced productivity in the previous week. Generalized estimating equation regression models were used to examine the baseline factors associated with recovery during follow-up. Clinical and functional remission was achieved in 70.6% and 56.1% of the MDD patients, respectively. MDD patients who achieved recovery (52.1%) were significantly less likely to have impaired levels of functioning, concurrent medical or psychiatric conditions, low levels of education, or nonadherence to therapy at follow-up. The level of functioning during the index episode seems to be a better predictor of recovery than symptom severity. Therefore, the level of functioning should be considered while determining recovery from depression.

The association between depression and craving in alcohol dependency is moderated by gender and by alexithymia factors

Alexithymia is a multifaceted personality trait that involves difficulties in identifying and describing feelings to others, a poor fantasy life and an externally oriented cognitive style. Alexithymia has been described as a vulnerability factor for mental and physical diseases. We investigated in a group of 158 alcohol-dependent patients (103 men, 55 women) the association between depression and craving for alcohol when these patients were starting a detoxification program, and the moderating impact of gender and alexithymia on this relation. We first found an interaction between depression and gender in the prediction of craving in the sense that only for women an increase in depressive mood was related to an increase in total craving. When examining gender separately, we found that alexithymia factors acted as moderators. For women, the link between depression and craving was strengthened for the ones scoring higher on "difficulties describing feelings". But for men, the link between depression and craving was reduced for the ones scoring higher on "externally-oriented thinking". These findings suggest that in some cases that need to be identified more systematically in the future, the "externally-oriented thinking" alexithymia factor can exert - at least in the short term - some protective effects.

Links Among High EPDS Scores, State of Mind Regarding Attachment, and Symptoms of Personality Disorder

Underlying persistent psychological difficulties have been found to moderate potential adverse effects of maternal postpartum depression (PPD) on parenting and infant development. The authors examined whether mothers presenting postpartum depressive symptoms showed higher levels of personality pathology and more insecure state of mind regarding attachment compared to nondepressed mothers. Participants (N = 85) were assessed with the Edinburgh Postnatal Depression Scale (EPDS), the Present State Examination, the Adult Attachment Interview, and the Structured Clinical Interview for DSM-IV Axis II. Mothers with high EPDS scores were more likely to have a preoccupied insecure state of mind and to have personality disorder compared with mothers scoring below clinical cutoff. Furthermore, multiple regression analysis showed that personality disorder and AAI classification were independently related to EPDS score, and that these two factors together accounted for 48% of the variance in EPDS score. Findings are discussed in terms of heterogeneity in PPD populations and underline the importance of examining potential coexisting psychological difficulties when studying PPD.

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.

Prognostic subgroups for citalopram response in the STAR*D trial

OBJECTIVE

Few data exist to help clinicians predict likelihood of treatment response in individual patients with major depressive disorder (MDD). Our aim was to identify subgroups of MDD patients with differential treatment outcomes based on presenting clinical characteristics. We also sought to quantify the likelihood of treatment success based on the degree of improvement and side effects after 2 and 4 weeks of selective serotonin reuptake inhibitor (SSRI) pharmacotherapy.

METHOD

We analyzed data from the first treatment phase of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, in which subjects with a DSM-IV diagnosis of MDD were treated for 8-14 weeks with open-label citalopram. A receiver operating characteristic (ROC) analysis was conducted to determine homogenous subgroups with different rates of response and remission in depressive symptoms. Included predictor variables were initial clinical characteristics, initial improvement, and side effects after 2 and 4 weeks of SSRI treatment. The primary outcome measures were treatment response (defined as a greater than 50% reduction in 17-item Hamilton Depression Rating Scale [HDRS-17] score from baseline) and remission (defined as an HDRS-17 score ≤ 17).

RESULTS

Baseline clinical characteristics were able to identify subgroups from a low likelihood of response of 18% (income < $10,000, comorbid generalized anxiety disorder, < 16 years of education; P < .01) to a high likelihood of response of 68% (income ≥ $40,000, no comorbid posttraumatic stress disorder; P < .01). Among baseline clinical characteristics, employment status (N = 2,477; χ²₁ = 78.1; P < .001) and income level (N = 2,512; χ²₁ = 77.7; P < .001) were the most informative in predicting treatment outcome. For the models at weeks 2 and 4, treatment success was best predicted by early symptom improvement.

CONCLUSIONS

Socioeconomic data such as low income, education, and unemployment were most discriminative in predicting a poor response to citalopram, even with disparities in access to care accounted for. This finding implies that socioeconomic factors may be more useful predictors of medication response than traditional psychiatric diagnoses or past treatment history.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00021528.

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.

Prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder

CONTEXT

The draft proposal to add Chronic Depressive Disorder to DSM-5 will combine DSM-IV Dysthymic Disorder and Major Depressive Disorder, with chronic specifier, into a single diagnosis.

OBJECTIVE

The objective of this study is to estimate the prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder using unit record data from the 2007 Australian National Survey of Mental Health and Wellbeing.

DESIGN

Secondary analysis of a nationally representative household survey.

SETTING

Urban and rural census tracts.

PARTICIPANTS

One individual between the ages of 16 and 85 years from 8841 households was interviewed for the survey.

MAIN OUTCOME MEASURE

Lifetime prevalence estimates for chronic and non-chronic depression were determined using data from the World Health Organization's Composite International Diagnostic Interview, version 3.0 (WMH-CIDI 3.0).

RESULTS

Chronic depression of at least two years' duration had a lifetime prevalence of 4.6% (95% CI: 3.9-5.3%) and was found in 29.4% (95% CI: 25.6-33.3%) of individuals with a lifetime depressive disorder. Higher rates of psychiatric co-morbidity (OR=1.42; 95% CI=1.26-1.61), older age (OR=1.04; 95% CI=1.02-1.05), a younger age of onset (OR=0.97; 95% CI=0.95-0.98) and more frequent episodes of depression (OR=1.75; 95% CI=1.07-2.86) were found to be significant correlates of chronic depression. The first episode of depression for individuals with chronic depression often developed after the death of someone close (OR=2.38; 95% CI 1.16-5.79).

CONCLUSIONS

Chronic depression is highly prevalent among community-residing persons and has a set of correlates that discriminate it from non-chronic depression. The distinction between chronic and non-chronic depression proposed for DSM-5, in the form of Chronic Depressive Disorder, seems to be warranted.

Approaches to understanding and addressing treatment-resistant depression: a scoping review

Treatment-resistant depression is associated with significant disability and, due to its high prevalence, results in substantive economic and societal burden at a population level. The objective of this study is to synthesize extant literature on approaches currently being applied to understand and address this condition. It is hoped that the findings can be used to inform practitioners and guide future research. A scoping review of the scientific literature was conducted with findings categorized and charted by underlying research paradigm. Currently, the vast majority of research stems from a biological paradigm (81%). Research on treatment-resistant depression would benefit from a broadened field of study. Given that multiple etiological mechanisms likely contribute to treatment-resistant depression and current efforts at prevention and treatment have substantial room for improvement, an expanded research agenda could more effectively address this significant public health issue.

Factors associated with life satisfaction in a 6-year follow-up of depressive out-patients

BACKGROUND

The major goal of mental health services is to improve mental health and thus also life satisfaction. However, studies assessing factors associated with life satisfaction during recovery from depression are lacking.

METHODS

A 6-year natural follow-up of 121 depressive out-patients was carried out with questionnaires at baseline, 1/2, 1, 2 and 6 years completed. A structured diagnostic interview was conducted. Throughout the follow-up, clinical status was assessed with several psychometric scales for life satisfaction (LS), depression (BDI, HDRS), hopelessness (HS), functional ability (GAF, SOFAS) and general psychopathology (SCL).

RESULTS

Men and women did not differ in their improvement in life satisfaction. Altogether, 77% of the patients at baseline and 22% at the end were dissatisfied. Life satisfaction on 6-year follow-up was associated with baseline lower interpersonal sensitivity (SCL subscale) and concurrently being loved by someone as well as with baseline and concurrent good self-rated health and wealth. The satisfied were better off in terms of all clinical variables, regardless of the measurement time. Depressive symptoms and hopelessness were the strongest concurrent clinical correlates of LS after 6 years.

CONCLUSIONS

Mental health was strongly related to life satisfaction throughout the follow-up, while most of the non-clinical factors were not. Alleviating depression and interpersonal sensitivity and supporting social networks should be focused on in psychiatric treatment in order to improve life satisfaction among depressive patients.

Mental health and well-being in a 6-year follow-up of patients with depression: assessments of patients and clinicians

BACKGROUND

Psychiatric patients have the right to strive for well-being and not only be confined to symptom reduction. Studies are needed to assess global well-being during recovery from depression by comparing the assessments of patients and clinicians.

METHOD

A 6-year natural follow-up of 185 depressive out-patients was carried out with health questionnaires at baseline, 0.5, 1, 2 and 6 years, including scales on depression (BDI, HDRS), general psychopathology (SCL), functional capacity (GAF, SOFAS) and life satisfaction (LS). A structured diagnostic interview was carried out at baseline, 2 and 6 years. Complete follow-up data were obtained from 121 patients.

RESULTS

In general, depressive patients mainly attained a normal mood, adequate functional capacity and life satisfaction. Those with a slow recovery improved with successive treatment contacts, eventually reaching levels of mental health not significantly different from the others. Throughout the follow-up, recovery was similarly shown with the self-reported BDI-21, SCL-90 and LS-4, while intercorrelations between clinician ratings were low at baseline.

CONCLUSIONS

Adequate mental health and global well-being can be reached among depressive patients, but it may take time in treatment. Subjective assessments are reliable. The 4-item life satisfaction scale is a global well-being indicator and a valid treatment outcome measure.

Partial remission indicates poor functioning and a high level of psychiatric symptoms: a 3-phase 6-year follow-up study on major depression

Patients with depression in partial remission are at high risk of relapse, but factors associated with being in this outcome group are not well known. We conducted a clinical survey to examine the course of major depression in 87 patients during a follow-up period of 6 years. Beck Depression Inventory (BDI) scores indicated the outcome of depression, i.e. remission, partial remission or fully symptomatic, at 6, 12 and 24 months and after 6 years. The prevalence of partial remission varied from 16% to 23% at different follow-ups. All symptom and functioning scale scores indicated at every assessment that the partial depression group managed better than those in the fully symptomatic group, but worse than those in remission. Partial remission was associated with a significant impairment in psychosocial functioning and a high level of symptoms throughout the follow-up. The partial remission group must be recognized and actively treated.

Long-term outcome of patients with dysthymia and panic disorder: a naturalistic 9-year follow-up study

The highly prevalent psychiatric disorders dysthymia and panic disorder have often a chronic or recurrent course with superimposed major depression. The prominent comorbidity between these diagnoses constitutes a confounding factor in the study of long-term outcome. We performed a 9-year follow-up of 38 patients with "pure" diagnoses, i.e. without comorbid dysthymia and panic disorder, selected from two 2-year naturalistic treatment studies with psychotherapy and antidepressant medication. The aims of the present study were to investigate 1) the stability of change, and 2) the impact of comorbid personality disorders (PDs) on long-term outcome. Patients were reassessed with SCID-I and SCID-II interviews, SCL-90/BSI and a detailed, modified life-charting interview, investigating course and treatment over time. About 50% of patients showed substantial improvement, of whom about half were in remission. Comorbid PD was a negative prognostic factor independently of Axis I diagnosis. Although patients with panic disorder had a lower frequency of comorbid PD, later onset, shorter duration of illness and better outcome after the original studies, there was no difference in the long-term outcome. The less stable outcome among panic patients suggests that standard treatments are not resulting in enduring remission. In order to achieve remission, it is necessary to 1) address comorbid PDs, 2) perform careful assessments of all comorbid diagnoses, and 3) build routines for the follow-up and augmentation of treatments.