Prevention of Relapse and Recurrence in Adults with Major Depressive Disorder: Systematic Review and Meta-Analyses of Controlled Trials

Glutamatergic Modulators for Major Depression from Theory to Clinical Use

Major depressive disorder (MDD) is a chronic, burdensome, highly prevalent disease that is characterized by depressed mood and anhedonia. MDD is especially burdensome as approved monoamine antidepressant treatments have weeks-long delays before clinical benefit and low remission rates. In the past 2 decades, a promising target emerged to improve patient outcomes in depression treatment: glutamatergic signaling. This narrative review provides a high-level overview of glutamate signaling in synaptogenesis and neural plasticity and the implications of glutamate dysregulation in depression. Based on this preclinical evidence implicating glutamate in depression and the rapid improvement of depression with ketamine treatment in a proof-of-concept trial, a range of N-methyl-D-aspartate (NMDA)-targeted therapies have been investigated. While an array of treatments has been investigated in registered phase 2 or 3 clinical trials, the development of most of these agents has been discontinued. Multiple glutamate-targeted antidepressants are actively in development, and two are approved. Nasal administration of esketamine (Spravato®) was approved by the US Food and Drug Administration (FDA) in 2019 to treat adults with treatment-resistant depression and in 2020 for adults with MDD with acute suicidal ideation or behavior. Oral combination dextromethorphan-bupropion (AXS-05, Auvelity® extended-release tablet) was FDA approved in 2022 for the treatment of MDD in adults. These approvals bolster the importance of glutamate in depression and represent an exciting breakthrough in contemporary psychiatry, providing new avenues of treatment for patients as first-line therapy or with either poor response or unacceptable side effects to monoaminergic antidepressants.

Association between duration of antidepressant treatment for major depressive disorder and relapse rate after discontinuation: A meta-analysis

The optimal duration of antidepressant treatment for patients with major depressive disorder to reduce the risk of relapse after discontinuation remains uncertain. Medline, Cochrane Central Register of Controlled Trials, and Embase were systematically searched for randomized controlled trials (RCTs) with a discontinuation design. A single-group summary meta-analysis was performed to calculate 6-month relapse rates after discontinuation. Meta-regression with restricted cubic splines was performed to model the non-linear relationship between treatment duration and relapse rate after discontinuation. Thirty-five RCTs were included. The relapse rate after discontinuation was approximately 34.81 % at 6 months and 45.12 % at 12 months. After controlling for covariates, the meta-analysis shows that the duration of treatment is associated with the risk of relapse after discontinuation in a non-linear curve, with a relatively higher risk of relapse observed for a duration of less than three months. There appears to be no further reduction in the risk of relapse when treatment is continued for over six months. Our results indicate the importance of at least three months of treatment to avoid the relatively high risk of relapse after discontinuation. The additional benefit of longer treatment remains to be proven.

Hypersomnolence is associated with non-remission of major depressive disorder

OBJECTIVE

This study aimed to investigate the prevalence, clinical correlates and the relationship between hypersomnolence and clinical outcomes in a cohort of MDD patients.

METHODS

This is a cross-sectional study of a MDD cohort in an university-affiliated adult psychiatric outpatient clinic. The diagnosis of MDD and severity of depression were ascertained by the clinician with structured clinical interviews. Each participant completed the Epworth Sleepiness Scale (ESS), 1-week sleep diary, and a battery of questionnaires that assessed usual sleep pattern, insomnia, anxiety, depression, fatigue and circadian preference. Hypersomnolence was defined as ESS score ≥14 among those reported ≥7 h of nighttime sleep. Univariate analysis and multiple logistic regression were used to analyze the relationships between the variables.

RESULTS

Among 252 recruited subjects, 11 % met the criteria of hypersomnolence as defined by a ESS score ≥14 despite ≥7 h of nighttime sleep. Patients with hypersomnolence had greater depression ratings, higher rates of suicidal ideations over the past week, and more likely to meet a diagnosis of atypical depression (p < 0.05) than those without hypersomnolence. Step-wise logistic regression demonstrated that hypersomnolence was an independent risk factor associated with a 3-fold increase in the risk of depression non-remission (adjusted OR 3.13; 95 % CI 1.10-8.95; p = 0.034).

CONCLUSION

Patients with hypersomnolence despite seemingly adequate sleep represent a subgroup of MDD patients who have a more severe illness profile with higher non-remission rate and suicidality. The findings highlight the importance of addressing both sleep and mood symptoms in the management of MDD.

Pathogenesis of depression and the potential for traditional Chinese medicine treatment

Depression is a prevalent mental disorder that significantly diminishes quality of life and longevity, ranking as one of the primary causes of disability globally. Contemporary research has explored the potential pathogenesis of depression from various angles, encompassing genetics, neurotransmitter systems, neurotrophic factors, the hypothalamic-pituitary-adrenal axis, inflammation, and intestinal flora, among other contributing factors. In addition, conventional chemical medications are plagued by delayed onset of action, persistent adverse effects, and restricted therapeutic efficacy. In light of these limitations, the therapeutic approach of traditional Chinese medicine (TCM) has gained increasing recognition for its superior effectiveness. Numerous pharmacological and clinical studies have substantiated TCM's capacity to mitigate depressive symptoms through diverse mechanisms. This article attempts to summarize the mechanisms involved in the pathogenesis of depression and to describe the characteristics of herbal medicines (including compounded formulas and active ingredients) for the treatment of depression. It further evaluates their effectiveness by correlating with the multifaceted pathogenesis of depression, thereby furnishing a reference for future research endeavors.

Gut microbiota and postpartum depression: a Mendelian randomization study

Background

Increasing evidence suggests a correlation between intestinal microbiota and the gut-brain axis; however, the causal relationship between gut microbiota and postpartum depression (PPD) remains unclear.

Methods

In this study, a two-sample Mendelian randomization (MR) design was employed to analyze the GWAS data of gut microorganisms from the Mibiogen database and PPD data from the UK biobank. Various statistical methods, including inverse variance weighted, MR-Egger, weighted median, weighted model, and MR-PRESSO, were utilized to investigate the causal relationship between gut microbiota and PPD. Additionally, sensitivity analysis was conducted to assess the robustness of the findings.

Results

Through MR analysis, it was found that phylum Actinobacteria (P=0.014, OR=0.971, 95% CI=0.948-0.994) and genus Holdemanella (P=0.023, OR=0.979, 95% CI=0.961-0.997) have protective effects on PPD, while the other two unknown genera, genus Unknown Ids 2001 (P=0.025, OR=0.972,95% CI=0.947-0.996), and genus Unknown Ids 2755 (P=0.012, OR=0.977, 95% CI=0.959-0.995) also has a protective effect on PPD. The sensitivity analysis results indicate that there is no heterogeneity or horizontal pleiotropy.

Conclusion

This study has identified a causal association between Actinomycetota, Holdemanella, and PDD through MR analysis. These findings offer significant contributions to the development of personalized treatment approaches for PPD, encompassing interventions such as dietary modifications or microbiome interventions.

Prediction of treatment response in major depressive disorder using a hybrid of convolutional recurrent deep neural networks and effective connectivity based on EEG signal

In this study, we have developed a novel method based on deep learning and brain effective connectivity to classify responders and non-responders to selective serotonin reuptake inhibitors (SSRIs) antidepressants in major depressive disorder (MDD) patients prior to the treatment using EEG signal. The effective connectivity of 30 MDD patients was determined by analyzing their pretreatment EEG signals, which were then concatenated into delta, theta, alpha, and beta bands and transformed into images. Using these images, we then fine tuned a hybrid Convolutional Neural Network that is enhanced with bidirectional Long Short-Term Memory cells based on transfer learning. The Inception-v3, ResNet18, DenseNet121, and EfficientNet-B0 models are implemented as base models. Finally, the models are followed by BiLSTM and dense layers in order to classify responders and non-responders to SSRI treatment. Results showed that the EfficiencyNet-B0 has the highest accuracy of 98.33, followed by DensNet121, ResNet18 and Inception-v3. Therefore, a new method was proposed in this study that uses deep learning models to extract both spatial and temporal features automatically, which will improve classification results. The proposed method provides accurate identification of MDD patients who are responding, thereby reducing the cost of medical facilities and patient care.

Emotional risk factors before in vitro fertilization among infertile couples in daily clinical practice in Sari in 2020-2022

BACKGROUND AND AIM

The relationship between psychological factors and treatment outcomes with assisted reproductive technology has sparked considerable debate. This study aims to investigate the emotional risk factors in couples seeking infertility treatment using assisted reproductive technology in Sari, Iran, from 2020 to 2022.

MATERIALS AND METHODS

This research is a cross-sectional study and emotional risk factors and other related factors were examined using the Persian version of the SCREENIVF demographic, social, and clinical status questionnaire, social, and clinical status questionnaire before using Assisted reproductive technology in 460 infertile couples selected from infertility treatment centers in Sari City, Iran. The samples were randomly selected using a table of random numbers. Data analysis was performed using SPSS version 22 software.

RESULTS

The mean age of the male and female participants were 31.70 ± 5.71 and 35.22 ± 5.48, respectively. The results regarding emotional risk factors and other related factors revealed that the variables of remarriage (P = 0.048) and exposure of spouse to emotional risk factors (P = 0.001), history of depression disorder (P = 0.007), and history of anxiety disorder (P = 0.009) were significantly correlated with the exposure of women to emotional risk factors. Furthermore, men's exposure to emotional risk factors was significantly correlated with primary education (P = 0.026) and diploma (P = 0.043) levels, age (P = 0.006), and wife's exposure to emotional risk factors (P = 0.001).

CONCLUSION

By identifying infertile couples who are at risk of emotional risk factors, healthcare professionals can provide appropriate support and interventions to mitigate the emotional challenges associated with infertility. This proactive approach can significantly enhance couples undergoing infertility treatment's well-being and mental health.

The evidence-based COPE program: Reducing the time between diagnosing and treating depression and anxiety in youth

ABSTRACT

The soaring prevalence of depression and anxiety in children, teenagers, and young adults is now a public health epidemic, yet access to timely evidence-based mental health treatment is often lacking due to a severe shortage of mental health providers. This article provides an overview of the current state of depression and anxiety in children and adolescents as well as first-line evidence-based treatment. The Creating Opportunities for Personal Empowerment (COPE) program, a cognitive-behavioral skills-building intervention, is highlighted as an evidence-based intervention for timely treatment that can be delivered by NPs, physicians, and physician associates/assistants in primary care settings, school-based health centers, and chronic care clinics with reimbursement as well as in schools and universities as a preventive mental health intervention.

Exploring Novel Antidepressants Targeting G Protein-Coupled Receptors and Key Membrane Receptors Based on Molecular Structures

Major Depressive Disorder (MDD) is a complex mental disorder that involves alterations in signal transmission across multiple scales and structural abnormalities. The development of effective antidepressants (ADs) has been hindered by the dominance of monoamine hypothesis, resulting in slow progress. Traditional ADs have undesirable traits like delayed onset of action, limited efficacy, and severe side effects. Recently, two categories of fast-acting antidepressant compounds have surfaced, dissociative anesthetics S-ketamine and its metabolites, as well as psychedelics such as lysergic acid diethylamide (LSD). This has led to structural research and drug development of the receptors that they target. This review provides breakthroughs and achievements in the structure of depression-related receptors and novel ADs based on these. Cryo-electron microscopy (cryo-EM) has enabled researchers to identify the structures of membrane receptors, including the N-methyl-D-aspartate receptor (NMDAR) and the 5-hydroxytryptamine 2A (5-HT2A) receptor. These high-resolution structures can be used for the development of novel ADs using virtual drug screening (VDS). Moreover, the unique antidepressant effects of 5-HT1A receptors in various brain regions, and the pivotal roles of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) and tyrosine kinase receptor 2 (TrkB) in regulating synaptic plasticity, emphasize their potential as therapeutic targets. Using structural information, a series of highly selective ADs were designed based on the different role of receptors in MDD. These molecules have the favorable characteristics of rapid onset and low adverse drug reactions. This review offers researchers guidance and a methodological framework for the structure-based design of ADs.

Lasting scars: The impact of depression in early adulthood on subsequent labor market outcomes

A growing body of evidence indicates that poor health early in life can leave lasting scars on adult health and economic outcomes. While much of this literature focuses on childhood experiences, mechanisms generating these lasting effects-recurrence of illness and interruption of human capital accumulation-are not limited to childhood. In this study, we examine how an episode of depression experienced in early adulthood affects subsequent labor market outcomes. We find that, at age 50, people who had met diagnostic criteria for depression when surveyed at ages 27-35 earn 10% lower hourly wages (conditional on occupation), work 120-180 fewer hours annually, and earn 24% lower annual wage incomes. A portion of this income penalty (21%-39%) occurs because depression is often a chronic condition, recurring later in life. But a substantial share (25%-55%) occurs because depression in early adulthood disrupts human capital accumulation, by reducing work experience and by influencing selection into occupations with skill distributions that offer lower potential for wage growth. These lingering effects of early depression reinforce the importance of early and multifaceted intervention to address depression and its follow-on effects in the workplace.

A systematic review of pharmacotherapy for attention-deficit/hyperactivity disorder in children and adolescents with bipolar disorders

INTRODUCTION

The data suggests that in children and adolescents, bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) may be strongly correlated. Even though drugs for ADHD and BD are largely accepted, there is relatively little research on the management of comorbidity in children and adolescents, particularly in terms of safety. We provide a synthesis of these findings because one hasn't been made yet.

AREAS COVERED

As a primary outcome, we wanted to determine whether stimulant or non-stimulant treatment of children and adolescents with ADHD and comorbid BD was effective. As a secondary outcome, we wanted to determine tolerability, especially the risk of mood switch.

EXPERT OPINION

The findings of this systematic review suggest that methylphenidate, when used with a mood stabilizer, may be safe and not significantly increase the risk of a manic switch or psychotic symptoms when used to treat ADHD that co-occurs with a BD. In situations where stimulants are ineffective or have low tolerance, atomoxetine also seems to be a good alternative, and also in cases of co-morbid anxiety, oppositional defiant disorder, conduct disorders, ICT disorders, and substance use disorders. Additional research with a higher level of evidence is necessary to corroborate these preliminary findings.

An update on pharmacotherapy for recurrent depression in 2022

INTRODUCTION

Major depressive disorder remains a major challenge due to its biopsychosocial burden with increased morbidity and mortality. Despite successful treatment options for the acute episode, recurrence rates are high, on average four times in a life span.

AREAS COVERED

Both pharmacological as non-pharmacological evidence-based therapeutic options to prevent and treat recurrent depression are discussed.

EXPERT OPINION

Although some risk factors for recurrence are well known, better evidence is needed. Antidepressant medication should be continued after acute treatment at its full therapeutic dose for longer periods, at least 1 year. There are no clear differences between classes of antidepressant medication when treatment is focused on preventing relapse. Bupropion is the only antidepressant with a proven efficacy to prevent recurrence in seasonal affective disorder. Recent findings conclude maintenance subanesthetic ketamine and esketamine treatment can be effective in sustaining antidepressant effect following remission. Furthermore, the pharmacological approach must be integrated with lifestyle interventions, especially aerobic exercise. Finally, combining pharma- and psychotherapy seems to improve outcome. Network and complexity sciences will help to decrease the high recurrence rates of MDD by developing more integrative and personalized approaches.

Inhibition of IL-6 methylation by Saikosaponin C regulates neuroinflammation to alleviate depression

PURPOSE

Saikosaponin C (SSc) increases the expression of synaptic proteins and has a unexplored role in the prevention of AD and other neurodegeneration in humans. Therefore, we hypothesized that SSc has the potential to relief of depressive symptoms. Here, our study assessed the role of SSc on depression-like behaviors caused by a chronic social defeat stress (CSDS) in mice and explored the underlying mechanisms.

METHODS

Behavioral tests were conducted to verify the efficacy of SSC in treating depression-like behavior in mice. The levels of IL-6, TNF-α and IL-1β in brain tissue and BV2 cells were determined by ELISA. The effect of SSc on dendritic spine density was determined by Golgi staining. The percentage of monocytes in peripheral blood was measured using flow cytometry. The levels of STAT3 and DNMT1 under the influence of SSc were assessed by immunofluorescence. Protein expression of DNMT1, DNMT3a, DNMT3b, p-STAT3 and STAT3 in brain and BV2 cells was studied by Western blot. OE-DNMT1 was induced in the experiment to verify the inhibitory effect of DNMT1 on IL-6 methylation in SSC. Luciferase was used to detect SSC specific fragments affecting IL-6 methylation.

RESULT

SSC treatment significantly alleviated depressive-like behavior, inhibited the levels of inflammatory cytokines including IL-6, IL-1β and TNF-α, increased dendritic spine density and promoted synaptic plasticity in mice. SSC downregulated IL-6, STAT3 and DNMT1 expression in vivo and in vitro. SSC also decreased the percentage of monocytes in peripheral blood and suppressed neuroinflammation in mice. Overexpression of DNMT1 by shRNA abolished the inhibitory effect of SSc on IL-6 methylation.

CONCLUSION

This study showed that SSc reduced IL6 methylation by inhibiting DNMT1 protein, induced a decrease in IL6 expression, promoted synaptic plasticity, and attenuated CSDS-induced depression-like behavior.

Machine learning based approaches for clinical and non-clinical depression recognition and depression relapse prediction using audiovisual and EEG modalities: A comprehensive review

Mental disorders are rapidly increasing each year and have become a major challenge affecting the social and financial well-being of individuals. There is a need for phenotypic characterization of psychiatric disorders with biomarkers to provide a rich signature for Major Depressive Disorder, improving the understanding of the pathophysiological mechanisms underlying these mental disorders. This comprehensive review focuses on depression and relapse detection modalities such as self-questionnaires, audiovisuals, and EEG, highlighting noteworthy publications in the last ten years. The article concentrates on the literature that adopts machine learning by audiovisual and EEG signals. It also outlines preprocessing, feature extraction, and public datasets for depression detection. The review concludes with recommendations that will help improve the reliability of developed models and the determinism of computational intelligence-based systems in psychiatry. To the best of our knowledge, this survey is the first comprehensive review on depression and relapse prediction by self-questionnaires, audiovisual, and EEG-based approaches. The findings of this review will serve as a useful and structured starting point for researchers studying clinical and non-clinical depression recognition and relapse through machine learning-based approaches.

Persistent Ventral Anterior Cingulate Cortex and Resolved Amygdala Hyper-responses to Negative Outcomes After Depression Remission: A Combined Cross-sectional and Longitudinal Study

BACKGROUND

Major depressive disorder (MDD) is a highly prevalent mood disorder affecting more than 300 million people worldwide. Biased processing of negative information and neural hyper-responses to negative events are hallmarks of depression. This study combined cross-sectional and longitudinal experiments to explore both persistent and resolved neural hyper-responses to negative outcomes from risky decision making in patients with current MDD (cMDD) and remitted MDD (rMDD).

METHODS

A total of 264 subjects participated in the cross-sectional study, including 117 patients with medication-naïve, first-episode current depression; 45 patients with rMDD with only 1 episode of depression; and 102 healthy control subjects. Participants completed a modified balloon analog risk task during functional magnetic resonance imaging. In the longitudinal arm of the study, 42 patients with cMDD were followed and 26 patients with rMDD were studied again after 8 weeks of antidepressant treatment.

RESULTS

Patients with cMDD showed hyper-responses to loss outcomes in multiple limbic regions including the amygdala and ventral anterior cingulate cortex (vACC). Amygdala but not vACC hyperactivity correlated with depression scores in patients with cMDD. Furthermore, amygdala hyperactivity resolved while vACC hyperactivity persisted in patients with rMDD in both cross-sectional and longitudinal studies.

CONCLUSIONS

These findings provide consistent evidence supporting differential patterns of amygdala and vACC hyper-responses to negative outcomes during depression remission. Amygdala hyperactivity may be a symptomatic and state-dependent marker of depressive neural responses, while vACC hyperactivity may reflect a persistent and state-independent effect of depression on brain function. These findings offer new insights into the neural underpinnings of depression remission and prevention of depression recurrence.

Examining clinician choice to follow-up (or not) on automated notifications of medication non-adherence by clinical decision support systems

BACKGROUND

Maintaining medication adherence can be challenging for people living with mental ill-health. Clinical decision support systems (CDSS) based on automated detection of problematic patterns in Electronic Health Records (EHRs) have the potential to enable early intervention into non-adherence events ("flags") through suggesting evidence-based courses of action. However, extant literature shows multiple barriers-perceived lack of benefit in following up low-risk cases, veracity of data, human-centric design concerns, etc.-to clinician follow-up in real-world settings. This study examined patterns in clinician decision making behaviour related to follow-up of non-adherence prompts within a community mental health clinic.

METHODS

The prompts for follow-up, and the recording of clinician responses, were enabled by CDSS software (AI²). De-identified clinician notes recorded after reviewing a prompt were analysed using a thematic synthesis approach-starting with descriptions of clinician comments, then sorting into analytical themes related to design and, in parallel, a priori categories describing follow-up behaviours. Hypotheses derived from the literature about the follow-up categories' relationships with client and medication-subtype characteristics were tested.

RESULTS

The majority of clients were Not Followed-up (n = 260; 78%; Followed-up: n = 71; 22%). The analytical themes emerging from the decision notes suggested contextual factors-the clients' environment, their clinical relationships, and medical needs-mediated how clinicians interacted with the CDSS flags. Significant differences were found between medication subtypes and follow-up, with Anti-depressants less likely to be followed up than Anti-Psychotics and Anxiolytics (χ² = 35.196, 44.825; p < 0.001; v = 0.389, 0.499); and between the time taken to action Followed-up₀ and Not-followed up₁ flags (M₀ = 31.78; M₁ = 45.55; U = 12,119; p < 0.001; η² = .05).

CONCLUSION

These analyses encourage actively incorporating the input of consumers and carers, non-EHR data streams, and better incorporation of data from parallel health systems and other clinicians into CDSS designs to encourage follow-up.

Decomposing Working Memory in Recurrent Major Depression: Impaired Encoding and Limited Maintenance Immune-to-Encoding Constraint

It is generally believed that working memory (WM) is dysfunctional in depression. However, whether this impaired performance originates from impaired encoding, maintenance or both stages is still unclear. Here, we aimed to decompose the abnormal characteristics of encoding and maintenance in patients with recurrent major depressive disorder (MDD). Thirty patients and thirty-nine healthy controls completed a spatial working memory task where the encoding time and the retention time could vary under different load levels. Encoding performance was assessed by comparing accuracies between short and long encoding times, and maintenance performance was assessed by comparing accuracies between short and long retention times. The results show a lower performance in depression than the controls. However, while the decreased accuracy by long retention (vs. short retention) was increased by a short encoding time in the control group, the retention performance of the depression group did not further suffer from the short encoding time. The generally impaired encoding, together with limited maintenance of immunity against the constrained encoding time, suggests a common bias for fixed internal processing over external processing in recurrent MDD. The paradigm provided in this study can be a convenient and efficient clinical test for assessing the WM encoding and maintenance function.

Updates on the Role of Probiotics against Different Health Issues: Focus on Lactobacillus

This review article is built on the beneficial effects of Lactobacillus against different diseases, and a special focus has been made on its effects against neurological disorders, such as depression, multiple sclerosis, Alzheimer's, and Parkinson's disease. Probiotics are live microbes, which are found in fermented foods, beverages, and cultured milk and, when administered in an adequate dose, confer health benefits to the host. They are known as "health-friendly bacteria", normally residing in the human gut and involved in maintaining homeostatic conditions. Imbalance in gut microbiota results in the pathophysiology of several diseases entailing the GIT tract, skin, immune system, inflammation, and gut-brain axis. Recently, the use of probiotics has gained tremendous interest, because of their profound effects on the management of these disease conditions. Recent findings suggest that probiotics enrichment in different human and mouse disease models showed promising beneficial effects and results in the amelioration of disease symptoms. Thus, this review focuses on the current probiotics-based products, different disease models, variable markers measured during trials, and evidence obtained from past studies on the use of probiotics in the prevention and treatment of different diseases, covering the skin to the central nervous system diseases.

Personalised app-based relapse prevention of depressive and anxiety disorders in remitted adolescents and young adults: a protocol of the StayFine RCT

INTRODUCTION

Youth in remission of depression or anxiety have high risks of relapse. Relapse prevention interventions may prevent chronicity. Aim of the study is therefore to (1) examine efficacy of the personalised StayFine app for remitted youth and (2) identify high-risk groups for relapse and resilience.

METHOD AND ANALYSIS

In this Dutch single-blind parallel-group randomised controlled trial, efficacy of app-based monitoring combined with guided app-based personalised StayFine intervention modules is assessed compared with monitoring only. In both conditions, care as usual is allowed. StayFine modules plus monitoring is hypothesised to be superior to monitoring only in preventing relapse over 36 months. Participants (N=254) are 13-21 years and in remission of depression or anxiety for >2 months. Randomisation (1:1) is stratified by previous treatment (no treatment vs treatment) and previous episodes (1, 2 or >3 episodes). Assessments include diagnostic interviews, online questionnaires and monitoring (ecological momentary assessment with optional wearable) after 0, 4, 12, 24 and 36 months. The StayFine modules are guided by certified experts by experience and based on preventive cognitive therapy and ingredients of cognitive behavioural therapy. Personalisation is based on shared decision-making informed by baseline assessments and individual symptom networks. Time to relapse (primary outcome) is assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia-lifetime version diagnostic interview. Intention-to-treat survival analyses will be used to examine the data. Secondary outcomes are symptoms of depression and anxiety, number and duration of relapses, global functioning, and quality of life. Mediators and moderators will be explored. Exploratory endpoints are monitoring and wearable outcomes.

ETHICS, FUNDING AND DISSEMINATION

The study was approved by METC Utrecht and is funded by the Netherlands Organisation for Health Research and Development (636310007). Results will be submitted to peer-reviewed scientific journals and presented at (inter)national conferences.

TRIAL REGISTRATION NUMBER

NCT05551468; NL8237.

Transitions in depression: if, how, and when depressive symptoms return during and after discontinuing antidepressants

Purpose

The aim of the current study is to provide insight into if, how, and when meaningful changes occur in individual patients who discontinue antidepressant medication. Agreement between macro-level quantitative symptom data, qualitative ratings, and micro-level Ecological Momentary Assessments is examined.

Methods

During and shortly after antidepressant discontinuation, depressive symptoms and ‘feeling down’ were measured in 56 participants, using the SCL-90 depression subscale weekly (macro-level) for 6 months, and 5 Ecological Momentary Assessments daily (micro-level) for 4 months (30.404 quantitative measurements in total). Qualitative information was also obtained, providing additional information to verify that changes were clinically meaningful.

Results

At the macro-level, an increase in depressive symptoms was found in 58.9% of participants that (a) was statistically reliable, (b) persisted for 3 weeks and/or required intervention, and (c) was clinically meaningful to patients. Of these increases, 30.3% happened suddenly, 42.4% gradually, and for 27.3% criteria were inconclusive. Quantitative and qualitative criteria showed a very high agreement (Cohen’s κ = 0.85) regarding if a participant experienced a recurrence of depression, but a moderate agreement (Cohen’s κ = 0.49) regarding how that change occurred. At the micro-level, 41.1% of participants experienced only sudden increases in depressed mood, 12.5% only gradual, 30.4% experienced both types of increase, and 16.1% neither.

Conclusion

Meaningful change is common in patients discontinuing antidepressants, and there is substantial heterogeneity in how and when these changes occur. Depressive symptom change at the macro-level is not the same as depressive symptom change at the micro-level.

A systematic meta-review of patient-level predictors of psychological therapy outcome in major depressive disorder

BACKGROUND

Psychological therapies are effective for treating major depressive disorder, but current clinical guidelines do not provide guidance on the personalization of treatment choice. Established predictors of psychotherapy treatment response could help inform machine learning models aimed at predicting individual patient responses to different therapy options. Here we sought to comprehensively identify known predictors.

METHODS

EMBASE, Medline, PubMed, PsycINFO were searched for systematic reviews with or without meta-analysis published until June 2020 to identify individual patient-level predictors of response to psychological treatments. 3113 abstracts were identified and 300 articles assessed. We qualitatively synthesized our findings by predictor category (sociodemographic; symptom profile; social support; personality features; affective, cognitive, and behavioural; comorbidities; neuroimaging; genetics) and treatment type. We used the AMSTAR 2 to evaluate the quality of included reviews.

RESULTS

Following screening and full-text assessment, 27 systematic reviews including 12 meta-analyses were eligible for inclusion. 74 predictors emerged for various psychological treatments, primarily cognitive behavioural therapy, interpersonal therapy, and mindfulness-based cognitive therapy.

LIMITATIONS

A paucity of studies examining predictors of psychological treatment outcome, as well as methodological heterogeneities and publication biases limit the strength of the identified predictors.

CONCLUSIONS

The synthesized predictors could be used to supplement clinical decision-making in selecting psychological therapies based on individual patient characteristics. These predictors could also be used as a priori input features for machine learning models aimed at predicting a given patient's likelihood of response to different treatment options for depression, and may contribute toward the development of patient-specific treatment recommendations in clinical guidelines.

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis

Objectives

The aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).

Methods

A systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.

Results

Thirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.

Conclusions

In patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.

Systematic review registration number

PROSPERO 2018: CRD42018103142.

Low predictive power of clinical features for relapse prediction after antidepressant discontinuation in a naturalistic setting

The risk of relapse after antidepressant medication (ADM) discontinuation is high. Predictors of relapse could guide clinical decision-making, but are yet to be established. We assessed demographic and clinical variables in a longitudinal observational study before antidepressant discontinuation. State-dependent variables were re-assessed either after discontinuation or before discontinuation after a waiting period. Relapse was assessed during 6 months after discontinuation. We applied logistic general linear models in combination with least absolute shrinkage and selection operator and elastic nets to avoid overfitting in order to identify predictors of relapse and estimated their generalisability using cross-validation. The final sample included 104 patients (age: 34.86 (11.1), 77% female) and 57 healthy controls (age: 34.12 (10.6), 70% female). 36% of the patients experienced a relapse. Treatment by a general practitioner increased the risk of relapse. Although within-sample statistical analyses suggested reasonable sensitivity and specificity, out-of-sample prediction of relapse was at chance level. Residual symptoms increased with discontinuation, but did not relate to relapse. Demographic and standard clinical variables appear to carry little predictive power and therefore are of limited use for patients and clinicians in guiding clinical decision-making.

Evolutive Pattern of Major Depressive Disorder among Young Patients

Background: Major depressive disorder (MDD) in young patients represents a real public health problem, with a concerning increase in its prevalence. Aim of the study: To observe and to document relevant information regarding the particularities and the evolutive clinical patterns of MDD in young patients (18–50 years). Material and methods: We conducted a retrospective cross-sectional descriptive study on 68 patients diagnosed with MDD, aged 18–50 years, admitted to the First Department of Psychiatry of the Clinical County Hospital of Târgu Mureș, Romania between January 1, 2019 and September 30, 2020. Data regarding the patients’ psychiatric evaluation (primary and secondary diagnosis, relapses, associated personality disorders, autolytic attempts, treatment options, evolution, comorbidities) and psychological evaluation (HAM-D, HAM-A, GAF) were analyzed. Results: The highest prevalence of MDD was found in the 41–50 years age group (66%), followed by the 31–40 years age group (24%). Regarding the GAF and HAM-D scales, 90% of patients had scores in the range of 41–50 and >20 respectively. We found a high prevalence of personality disorders (75%), the most common being borderline personality disorder (27%). Younger patients (18–35 years) tended to recover quicker, with an average of 8.15 hospitalization days compared to older patients (36–50 years) who had an average of 12 days. Relapses were present in 55% of cases, being more frequent in women, and there was a 50% rate of relapse in subjects with no social support network. Autolytic attempts were present in 25% of cases and insomnia in 92%. Conclusions: MDD has a major impact on the patients’ global functionality and their quality of life. In our study, women were more vulnerable to develop MDD, while younger adults were less prone to develop MDD and they recovered more quickly.

Optimization of measurement-based care (OMBC) for depression based on all-round and continuous assessment: rationale and protocol for a multicenter randomized control clinical trial

BACKGROUND

Despite the recent findings presenting the benefits of measurement-based care (MBC) compared to treatment as usual (TAU), MBC is still not the standard of care used in clinical settings. The aim of the present study was to achieve the optimization of MBC (OMBC) for major depressive disorder (MDD) by establishing a comprehensive MBC framework based on all-round, continuous assessment for depression.

METHODS

The target recruitment size is 900 patients, and the study is conducted at 8 centers in China. The patients are randomly assigned to the MBC and TAU groups at a 2:1 ratio. The subjects are scheduled to remain for 12 weeks in the acute phase and for 12 months in the maintenance phase. The primary outcomes are the complete remission rate and the proportion of patients with a 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR 16) total score ≤ 5 of the MBC and TAU groups at the acute phase, and the recurrence rate/time between the two groups is measured at the maintenance phase. Secondary outcomes included the changes in the parameters QIDS-SR 16, Patient Health Questionnaire-9 (PHQ-9), and 17-item Hamilton Rating Scale for Depression (HAMD-17) from baseline and the response rate between the two groups at the acute phase as well as the comparison of recurrence rate between the two groups at the end of the study.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-OOC-17012566 . The registration was performed retrospectively on 4 September 2017.

Late-Life Depression, Cognitive Impairment, and Relationship with Alzheimer's Disease

This narrative review aimed to explore the existing knowledge in order to examine the multiple forms of late-life depression (LLD) within a non-neurodegenerative or a neurodegenerative context, in particular Alzheimer's disease (AD). This review will first provide information about different pathogenic hypotheses proposed to describe LLD when it is not linked to a neurodegenerative context. Within the presentation of these syndromes, the literature reports thymic and cognitive specific features and highlights a common preponderance of cognitive impairment, and particularly executive. This review will also report data from research works that have addressed the role of depressive symptoms (DSs) in incidence of AD and mild cognitive impairment (MCI) conversion to AD. These findings support the claim that the relationship between DS (or LLD) and the cognitive decline encountered in AD can be of 2 types: (1) risk factor or (2) prodrome. They also support the hypothesis that the effect of DS on the incidence of AD can be identified between specific characteristics of these symptoms such as a very first apparition late in life, an increasing severity of DS, and a poor response to medical treatment. Finally, longitudinal and cross-sectional research will be presented, aiming to identify the predictive value of DS (or LLD) on AD incidence and/or conversion of MCI (and specifically amnestic MCI). This final section shows that specific features of LLD, such as being of early- or late-onset, can be considered as indices of AD incidence.

Incremental burden of relapse in patients with major depressive disorder: a real-world, retrospective cohort study using claims data

BACKGROUND

Relapse is common in major depressive disorder (MDD). In this study, we evaluated the incremental health care burden of relapse in patients with MDD.

METHODS

This real-world retrospective cohort study used administrative medical and pharmacy claims data to identify commercially insured adult patients in the United States diagnosed with MDD who initiated a new antidepressant between January 1, 2012, and September 30, 2017. All-cause health care resource utilization, total costs, and medication adherence were evaluated in two cohorts: patients with and patients without relapse. Relapse was defined as suicide attempts, psychiatric hospitalization, mental health-related emergency department (ED) visit, use of electroconvulsive therapy, or reinitiation of treatment after a gap ≥6 months.

RESULTS

The study population included 14,186 patients (7093 baseline-matched patients per cohort). The mean follow-up period was 27.5 and 26.0 months for patients with and patients without relapse, respectively. Patients with relapse had significantly higher rates of hospitalization (16.6% vs 8.5%; p < .0001) and ED visits (54.8% vs 34.7%; p < .0001) than patients without relapse. The total costs for patients with relapse were significantly higher ($12,594 vs $10,445;  p < .0001). Patients with relapse were also less adherent to antidepressants (mean proportion of days covered, 0.43 vs 0.49; p < .0001).

CONCLUSIONS

Relapse of MDD was associated with increased total costs and health care utilization and lower adherence to antidepressants. Reducing the risk of relapse may result in a reduction of the associated health care burden; however, findings may only be generalizable to patients with commercial insurance.

Emotional Reactivity, Emotion Regulation, and Social Emotions in Affective Disorders

Abstract. Affective disorders, specifically Major Depressive Disorder and Bipolar Disorders, show high prevalence, relapse rates, and a high likelihood to develop a chronic course. For the past two decades, research has investigated the neural correlates of emotion processing and emotion regulation in patients with affective disorders. Putative underlying causal mechanisms of dysregulated affect have been informed by knowledge from the intersection of neuroimaging and clinical psychology. More recent investigations also consider processing the role of mostly negative, self-blaming social emotions, which have been linked to treatment resistance and, hence, provide a prolific target for intervention. Several psychotherapeutic treatment approaches already focus on emotion, and here specific knowledge about the mechanisms underlying persistent changes in affect bears the potential to improve the treatment of affective disorders. In this narrative review, we delineate why and how our insights into the neural correlates of emotion processing and regulation can be applied to the treatment of patients with affective disorders.

Mechanisms underlying antidepressant effect of transcutaneous auricular vagus nerve stimulation on CUMS model rats based on hippocampal α7nAchR/NF-κB signal pathway

Background

Stress-induced neuroinflammation was considered to play a critical role in the pathogenesis of depression. Transcutaneous auricular vagus nerve stimulation (taVNS) is a relatively non-invasive alternative treatment for patients suffering from major depressive disorder. The anti-inflammatory signal of vagus nerve is mediated by α7 nicotinic acetylcholine receptor (α7nAchR), and the hippocampus, the region with the most distribution of α7nAchR, regulates emotions. Here, we investigated the role of α7nAchR mediating hippocampal neuroinflammation in taVNS antidepressant effect though homozygous α7nAChR (−/−) gene knockout and α7nAchR antagonist (methyllycaconitine, MLA).

Methods

There were control, model, taVNS, α7nAChR(−/−) + taVNS, hippocampus (Hi) MLA + taVNS and Hi saline + taVNS groups. We used the chronic unpredicted mild stress (CUMS) method to establish depressive model rats for 42 days, excepting control group. After the successful modeling, except the control and model, the rats in the other groups were given taVNS, which was applied through an electroacupuncture apparatus at the auricular concha (2/15 Hz, 2 mA, 30 min/days) for 21 days. Behavioral tests were conducted at baseline, after modeling and after taVNS intervention, including sucrose preference test (SPT), open field test (OFT) and forced swimming test (FST). These tests are widely used to evaluate depression-like behavior in rats. The samples were taken after experiment, the expressions of α7nAchR, NF-κB p65, IL-1β and the morphology of microglia were detected.

Results

Depression-like behavior and hippocampal neuroinflammation in CUMS model rats were manifested by down-regulated expression of α7nAchR, up-regulated expression of NF-κB p65 and IL-1β, and the morphology of microglia was in amoebic-like activated state. TaVNS could significantly reverse the above-mentioned phenomena, but had rare improvement effect for α7nAChR(−/−) rats and Hi MLA rats.

Conclusion

The antidepressant effect of taVNS is related to hippocampal α7nAchR/NF-κB signal pathway.

More treatment but no less depression: The treatment-prevalence paradox

Treatments for depression have improved, and their availability has markedly increased since the 1980s. Mysteriously the general population prevalence of depression has not decreased. This "treatment-prevalence paradox" (TPP) raises fundamental questions about the diagnosis and treatment of depression. We propose and evaluate seven explanations for the TPP. First, two explanations assume that improved and more widely available treatments have reduced prevalence, but that the reduction has been offset by an increase in: 1) misdiagnosing distress as depression, yielding more "false positive" diagnoses; or 2) an actual increase in depression incidence. Second, the remaining five explanations assume prevalence has not decreased, but suggest that: 3) treatments are less efficacious and 4) less enduring than the literature suggests; 5) trial efficacy doesn't generalize to real-world settings; 6) population-level treatment impact differs for chronic-recurrent versus non-recurrent cases; and 7) treatments have some iatrogenic consequences. Any of these seven explanations could undermine treatment impact on prevalence, thereby helping to explain the TPP. Our analysis reveals that there is little evidence that incidence or prevalence have increased as a result of error or fact (Explanations 1 and 2), and strong evidence that (a) the published literature overestimates short- and long-term treatment efficacy, (b) treatments are considerably less effective as deployed in "real world" settings, and (c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases. Collectively, these a-c explanations likely account for most of the TPP. Lastly, little research exists on iatrogenic effects of current treatments (Explanation 7), but further exploration is critical.

Implementation of a web-based computerised decision support system for Community Mental Health Services using national electronic health records (Preprint)

Background

A high proportion of patients with severe mental illness relapse due to nonadherence to psychotropic medication. In this paper, we use the normalization process theory (NPT) to describe the implementation of a web-based clinical decision support system (CDSS) for Community Mental Health Services (CMHS) called Actionable Intime Insights or AI². AI² has two distinct functions: (1) it provides an overview of medication and treatment history to assist in reviewing patient adherence and (2) gives alerts indicating nonadherence to support early intervention.

Objective

Our objective is to evaluate the pilot implementation of the AI² application to better understand the challenges of implementing a web-based CDSS to support medication adherence and early intervention in CMHS.

Methods

The NPT and participatory action framework were used to both explore and support implementation. Qualitative data were collected over the course of the 14-month implementation, in which researchers were active participants. Data were analyzed and coded using the NPT framework. Qualitative data included discussions, meetings, and work products, including emails and documents.

Results

This study explores the barriers and enablers of implementing a CDSS to support early intervention within CMHS using Medicare data from Australia’s national electronic record system, My Health Record (MyHR). The implementation was a series of ongoing negotiations, which resulted in a staged implementation with compromises on both sides. Clinicians were initially hesitant about using a CDSS based on MyHR data and expressed concerns about the changes to their work practice required to support early intervention. Substantial workarounds were required to move the implementation forward. This pilot implementation allowed us to better understand the challenges of implementation and the resources and support required to implement and sustain a model of care based on automated alerts to support early intervention.

Conclusions

The use of decision support based on electronic health records is growing, and while implementation is challenging, the potential benefits of early intervention to prevent relapse and hospitalization and ensure increased efficiency of the health care system are worth pursuing.

Electroconvulsive therapy and psychiatric readmission in major depressive disorder - A population-based register study

OBJECTIVE

The primary aim was to determine whether electroconvulsive therapy (ECT) is associated with reduced risk of psychiatric readmission in major depressive disorder (MDD).

METHODS

This study was based on data from multiple Swedish population-based registries. All adult patients admitted to any Swedish hospital for moderate-to-severe MDD between 2012 and 2018 were included. Participants were divided into two groups depending on whether they received ECT during inpatient care. Follow-up was set at 30 and 90 days from discharge. Data were analyzed using logistic regression, and matching was conducted.

RESULTS

A total of 27,851 unique patients contributed to 41,916 admissions. ECT was used in 26.8% of admissions. In the main multivariate analysis, the risk of both 30- and 90-day readmission was lower in the ECT group than in the non-ECT group. In a matched sensitivity model, the results pointed in the same direction for readmission risk within 30 days, but statistical significance was not reached. ECT-treated subgroups with superior outcomes on readmission risk compared with non-ECT treatment were older, unemployed, married, or widowed patients, those treated with antipsychotics or benzodiazepines before admission, with psychotic features, prior psychiatric hospitalizations, or family history of suicide. However, in patients below 35 years of age, ECT was associated with increased readmission risk.

CONCLUSION

This study suggests that ECT reduces the risk of psychiatric readmission in certain subgroups of patients with MDD. Since patients receiving ECT tend to be more difficult to treat, there is a risk of residual confounding.

Antidepressant medication to prevent depression relapse in primary care: the ANTLER RCT

BACKGROUND

There has been a steady increase in the number of primary care patients receiving long-term maintenance antidepressant treatment, despite limited evidence of a benefit of this treatment beyond 8 months.

OBJECTIVE

The ANTidepressants to prevent reLapse in dEpRession (ANTLER) trial investigated the clinical effectiveness and cost-effectiveness of antidepressant medication in preventing relapse in UK primary care.

DESIGN

This was a Phase IV, double-blind, pragmatic, multisite, individually randomised parallel-group controlled trial, with follow-up at 6, 12, 26, 39 and 52 weeks. Participants were randomised using minimisation on centre, type of antidepressant and baseline depressive symptom score above or below the median using Clinical Interview Schedule - Revised (two categories). Statisticians were blind to allocation for the outcome analyses.

SETTING

General practices in London, Bristol, Southampton and York.

PARTICIPANTS

Individuals aged 18-74 years who had experienced at least two episodes of depression and had been taking antidepressants for ≥ 9 months but felt well enough to consider stopping their medication. Those who met an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of depression or with other psychiatric conditions were excluded.

INTERVENTION

At baseline, participants were taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg. They were randomised to either remain on their current medication or discontinue medication after a tapering period.

MAIN OUTCOME MEASURES

The primary outcome was the time, in weeks, to the beginning of the first depressive episode after randomisation. This was measured by a retrospective Clinical Interview Schedule - Revised that assessed the onset of a depressive episode in the previous 12 weeks, and was conducted at 12, 26, 39 and 52 weeks. The depression-related resource use was collected over 12 months from medical records and patient-completed questionnaires. Quality-adjusted life-years were calculated using the EuroQol-5 Dimensions, five-level version.

RESULTS

Between 9 March 2017 and 1 March 2019, we randomised 238 participants to antidepressant continuation (the maintenance group) and 240 participants to antidepressant discontinuation (the discontinuation group). The time to relapse of depression was shorter in the discontinuation group, with a hazard ratio of 2.06 (95% confidence interval 1.56 to 2.70; p < 0.0001). By 52 weeks, relapse was experienced by 39% of those who continued antidepressants and 56% of those who discontinued antidepressants. The secondary analysis revealed that people who discontinued experienced more withdrawal symptoms than those who remained on medication, with the largest difference at 12 weeks. In the discontinuation group, 37% (95% confidence interval 28% to 45%) of participants remained on their randomised medication until the end of the trial. In total, 39% (95% confidence interval 32% to 45%) of participants in the discontinuation group returned to their original antidepressant compared with 20% (95% confidence interval 15% to 25%) of participants in maintenance group. The health economic evaluation demonstrated that participants randomised to discontinuation had worse utility scores at 3 months (-0.037, 95% confidence interval -0.059 to -0.015) and fewer quality-adjusted life-years over 12 months (-0.019, 95% confidence interval -0.035 to -0.003) than those randomised to continuation. The discontinuation pathway, besides giving worse outcomes, also cost more [extra £2.71 per patient over 12 months (95% confidence interval -£36.10 to £37.07)] than the continuation pathway, although the cost difference was not significant.

CONCLUSIONS

Patients who discontinue long-term maintenance antidepressants in primary care are at increased risk of relapse and withdrawal symptoms. However, a substantial proportion of patients can discontinue antidepressants without relapse. Our findings will give patients and clinicians an estimate of the likely benefits and harms of stopping long-term maintenance antidepressants and improve shared decision-making. The participants may not have been representative of all people on long-term maintenance treatment and we could study only a restricted range of antidepressants and doses. Identifying patients who will not relapse if they discontinued antidepressants would be clinically important.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15969819 and EudraCT 2015-004210-26.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 69. See the NIHR Journals Library website for further project information.

The effect of thyroid function on the risk of psychiatric readmission after hospitalization for major depressive disorder

The relationship between thyroid function and depression has long been recognized, but little is known about the effect of thyroid function on the risk of readmission after hospitalization for major depressive disorder (MDD). This retrospective cohort study was aimed to explore the effect of thyroid function on psychiatric readmission after hospitalization for MDD. Data was derived from electronic medical records (EMR) of the Shanghai Mental Health Center (SMHC), Shanghai, China. Univariate and multivariate logistic regression analyses were conducted in subjects aged ≥ 18 years who had been hospitalized for MDD between January 1, 2007, and May 31, 2019. Of the 1803 eligible patients, 85 and 132 patients experienced psychiatric readmission within 90 days and 180 days after discharge respectively. Multivariate analyses showed that serum FT3 level (aOR=1.271; 95%CI=1.051-1.537) and comorbidity of thyroid disease (aOR=2,179; 95%CI=1.136-4.179) was independently associated with the risk of 90-day and 180-day readmission respectively. These findings indicated that high serum FT3 levels and comorbidity of thyroid disease could increase the risk of readmission after hospitalization for MDD. It is warranted to provide routine assessment and intervention of the thyroid function during the treatment of depression so as to prevent re-hospitalization.

Cognitive Behavioral Therapy to Sustain the Antidepressant Effects of Ketamine in Treatment-Resistant Depression: A Randomized Clinical Trial

INTRODUCTION

Ketamine has emerged as a rapid-acting antidepressant. While ongoing treatment can prevent relapse, concerns exist regarding long-term exposure.

OBJECTIVE

We conducted a randomized trial to examine the feasibility and efficacy of cognitive behavioral therapy (CBT) following intravenous ketamine in treatment-resistant depression (TRD).

METHODS

Subjects with TRD were recruited and treated with 6 intravenous infusions of ketamine over 3 weeks. Subjects who experienced a clinical response (≥50% improvement in depression severity) were then randomized to receiving CBT or treatment as usual (TAU) for an additional 14 weeks, using a sequential treatment model.

RESULTS

Of the 42 patients who signed consent, 28 patients achieved a response and were randomized to CBT or TAU. When measured using the Montgomery-Asberg Depression Rating Scale (primary outcome measure), the effect size at the end of the study was moderate (Cohen d = 0.65; 95% CI -0.55 to 1.82), though the group-by-time interaction effect was not significant. There was a significant group-by-time interaction as measured by the Quick Inventory of Depressive Symptomatology (F = 4.58; p = 0.033), favoring a greater sustained improvement in the CBT group. This corresponded to a moderate-to-large effect size of the Cohen d = 0.71 (95% CI -0.30 to 1.70) at the end of the study (14 weeks following the last ketamine infusion). In a subset of patients (N = 20) who underwent cognitive testing using the emotional N-back assessments before and after ketamine, ketamine responders showed improvement in the accuracy of emotional N-back (t[8] = 2.33; p < 0.05) whereas nonresponders did not (t[10] <1; p ns).

CONCLUSIONS

This proof-of-concept study provides preliminary data indicating that CBT may sustain the antidepressant effects of ketamine in TRD. Further study and optimization of this treatment approach in well-powered clinical trials is recommended.

Initial treatment choices to achieve sustained response in major depression: a systematic review and network meta-analysis

Major depression is often a relapsing disorder. It is therefore important to start its treatment with therapies that maximize the chance of not only getting the patients well but also keeping them well. We examined the associations between initial treatments and sustained response by conducting a network meta-analysis of randomized controlled trials (RCTs) in which adult patients with major depression were randomized to acute treatment with a psychotherapy (PSY), a protocolized antidepressant pharmacotherapy (PHA), their combination (COM), standard treatment in primary or secondary care (STD), or pill placebo, and were then followed up through a maintenance phase. By design, acute phase treatment could be continued into the maintenance phase, switched to another treatment or followed by discretionary treatment. We included 81 RCTs, with 13,722 participants. Sustained response was defined as responding to the acute treatment and subsequently having no depressive relapse through the maintenance phase (mean duration: 42.2±16.2 weeks, range 24-104 weeks). We extracted the data reported at the time point closest to 12 months. COM resulted in more sustained response than PHA, both when these treatments were continued into the maintenance phase (OR=2.52, 95% CI: 1.66-3.85) and when they were followed by discretionary treatment (OR=1.80, 95% CI: 1.21-2.67). The same applied to COM in comparison with STD (OR=2.90, 95% CI: 1.68-5.01 when COM was continued into the maintenance phase; OR=1.97, 95% CI: 1.51-2.58 when COM was followed by discretionary treatment). PSY also kept the patients well more often than PHA, both when these treatments were continued into the maintenance phase (OR=1.53, 95% CI: 1.00-2.35) and when they were followed by discretionary treatment (OR=1.66, 95% CI: 1.13-2.44). The same applied to PSY compared with STD (OR=1.76, 95% CI: 0.97-3.21 when PSY was continued into the maintenance phase; OR=1.83, 95% CI: 1.20-2.78 when PSY was followed by discretionary treatment). Given the average sustained response rate of 29% on STD, the advantages of PSY or COM over PHA or STD translated into risk differences ranging from 12 to 16 percentage points. We conclude that PSY and COM have more enduring effects than PHA. Clinical guidelines on the initial treatment choice for depression may need to be updated accordingly.

Maintenance or Discontinuation of Antidepressants in Primary Care

BACKGROUND

Patients with depression who are treated in primary care practices may receive antidepressants for prolonged periods. Data are limited on the effects of maintaining or discontinuing antidepressant therapy in this setting.

METHODS

We conducted a randomized, double-blind trial involving adults who were being treated in 150 general practices in the United Kingdom. All the patients had a history of at least two depressive episodes or had been taking antidepressants for 2 years or longer and felt well enough to consider stopping antidepressants. Patients who had received citalopram, fluoxetine, sertraline, or mirtazapine were randomly assigned in a 1:1 ratio to maintain their current antidepressant therapy (maintenance group) or to taper and discontinue such therapy with the use of matching placebo (discontinuation group). The primary outcome was the first relapse of depression during the 52-week trial period, as evaluated in a time-to-event analysis. Secondary outcomes were depressive and anxiety symptoms, physical and withdrawal symptoms, quality of life, time to stopping an antidepressant or placebo, and global mood ratings.

RESULTS

A total of 1466 patients underwent screening. Of these patients, 478 were enrolled in the trial (238 in the maintenance group and 240 in the discontinuation group). The average age of the patients was 54 years; 73% were women. Adherence to the trial assignment was 70% in the maintenance group and 52% in the discontinuation group. By 52 weeks, relapse occurred in 92 of 238 patients (39%) in the maintenance group and in 135 of 240 (56%) in the discontinuation group (hazard ratio, 2.06; 95% confidence interval, 1.56 to 2.70; P<0.001). Secondary outcomes were generally in the same direction as the primary outcome. Patients in the discontinuation group had more symptoms of depression, anxiety, and withdrawal than those in the maintenance group.

CONCLUSIONS

Among patients in primary care practices who felt well enough to discontinue antidepressant therapy, those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy. (Funded by the National Institute for Health Research; ANTLER ISRCTN number, ISRCTN15969819.).

Psychopharmacologic Therapies for Irritable Bowel Syndrome

Psychopharmacologic therapies are beneficial in reducing symptoms when treating irritable bowel syndrome (IBS) and other disorders of gut-brain interaction (DGBI). Noradrenaline, serotonin, and dopamine are neurotransmitters of key importance in psychopharmacology and pain-reduction mechanisms. The first-line (tricyclic antidepressants, serotonin noradrenaline reuptake inhibitors, selective serotonin reuptake inhibitors) and second-line (atypical antipsychotics, delta-ligand agents, low-dose naltrexone) neuromodulator treatment options are recommended when IBS-associated abdominal pain is of moderate or severe intensity and is persistent. To understand the implementation strategy, the multidimensional clinical profile as a template is used for presenting 3 case scenarios involving painful IBS and DGBI of varying complexity.

Multi-gene Pharmacogenomic Testing That Includes Decision-Support Tools to Guide Medication Selection for Major Depression: A Health Technology Assessment

BACKGROUND

Major depression is a substantial public health concern that can affect personal relationships, reduce people's ability to go to school or work, and lead to social isolation. Multi-gene pharmacogenomic testing that includes decision-support tools can help predict which depression medications and dosages are most likely to result in a strong response to treatment or to have the lowest risk of adverse events on the basis of people's genes.We conducted a health technology assessment of multi-gene pharmacogenomic testing that includes decision-support tools for people with major depression. Our assessment evaluated effectiveness, safety, cost-effectiveness, the budget impact of publicly funding multi-gene pharmacogenomic testing, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias Tool and the Risk of Bias Assessment Tool for Nonrandomized studies (RoBANS) and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.We performed a systematic literature search of the economic evidence to review published cost-effectiveness studies on multi-gene pharmacogenomic testing that includes a decision-support tool in people with major depression. We developed a state-transition model and conducted a probabilistic analysis to determine the incremental cost of multi-gene pharmacogenomic testing versus treatment as usual per quality-adjusted life-year (QALY) gained for people with major depression who had inadequate response to one or more antidepressant medications. In the reference case (with GeneSight-guided care), we considered a 1-year time horizon with an Ontario Ministry of Health perspective. We also estimated the 5-year budget impact of publicly funding multi-gene pharmacogenomic testing for people with major depression in Ontario.To contextualize the potential value of multi-gene pharmacogenomic testing that includes decision-support tools, we spoke with people who have major depression and their families.

RESULTS

We included 14 studies in the clinical evidence review that evaluated six multi-gene pharmacogenomic tests. Although all tests included decision-support tools, they otherwise differed greatly, as did study design, populations included in studies, and outcomes reported. Little or no improvement was observed on change in HAM-D17 depression score compared with treatment as usual for any test evaluated (GRADE: Low-Very Low). GeneSight- and NeuroIDgenetix-guided medication selection led to statistically significant improvements in response (GRADE: Low-Very Low) and remission (GRADE: Low-Very Low), while treatment guided by CNSdose led to significant improvement in remission rates (GRADE: Low), but the study did not report on response. Results were inconsistent and uncertain for the impact of Neuropharmagen, and no significant improvement was observed for Genecept or another unspecified test for either response or remission (GRADE: Low-Very Low). Neuropharmagen may reduce adverse events and CNSDose may reduce intolerability to medication, while no difference was observed in adverse events with GeneSight, Genecept, or another unspecified test (GRADE: Moderate-Very Low). No studies reported data on suicide, treatment adherence, relapse, recovery, or recurrence of depression symptoms.Our review included four model-based economic studies and found that multi-gene pharmacogenomic testing was associated with greater effectiveness and cost savings than treatment as usual, over long-term (i.e., 3-,5-year and lifetime) time horizons. Since none of the included studies was fully applicable to the Ontario health care system, we conducted a primary economic evaluation.Our reference case analysis over the 1-year time horizon found that multi-gene pharmacogenomic testing (with GeneSight) was associated with additional QALYs (0.03, 95% credible interval [CrI]: 0.005; 0.072) and additional costs ($1,906, 95% Crl: $688; $3,360). An incremental cost-effectiveness ratio was $60,564 per QALY gained. The probability of the intervention being cost-effective (vs. treatment as usual) was 36.8% at a willingness-to-pay amount of $50,000 per QALY (i.e., moderately likely not to be cost-effective), rising to 70.7% at a willingness-to-pay amount of $100,000 per QALY (i.e., moderately likely to be cost-effective). Evidence informing economic modeling of the reference case with GeneSight and other multi-gene pharmacogenomic tests was of low to very low quality, implying considerable uncertainty or low confidence in the effectiveness estimates. The price of the test, efficacy of the intervention on remission, time horizon, and analytic perspective were major determinants of the cost-effectiveness results. If the test price were assumed to be $2,162 (compared with $2,500 in the reference case), the intervention would be cost-effective at a willingness-to-pay amount of $50,000 per QALY; moreover, if the price decreased to $595, the intervention would be cost saving (or dominant) compared with treatment as usual.At an increasing uptake of 1% per year and a test price of $2,500, the annual budget impact of publicly funding multi-gene pharmacogenomic testing in Ontario over the next 5 years ranged from an additional $3.5 million in year 1 (at uptake of 1%) to $16.8 million in year 5. The 5-year budget impact was estimated at about $52 million.People with major depression and caregivers generally supported multi-gene pharmacogenomic testing because they believed it could provide guidance that fit their values. They hoped such guidance would speed symptom relief, would reduce side effects and help inform their medication choices. Some patients expressed concerns over maintaining confidentiality of test results and the possibility that physicians would sacrifice patient-centred care to follow pharmacogenomic guidance.

CONCLUSIONS

Multi-gene pharmacogenomic testing that includes decision-support tools to guide medication selection for depression varies widely. Differences between individual tests must be considered, as clinical utility observed with one test might not apply to other tests. Overall, effectiveness was inconsistent among the six multi-gene pharmacogenomic tests we identified. Multi-gene pharmacogenomic tests may result in little or no difference in improvement in depression scores compared with treatment as usual, but some tests may improve response to treatment or remission from depression. The impact on adverse events is uncertain. The evidence, however, is uncertain, and therefore our confidence that these observed effects reflect the true effects is low to very low.For the management of major depression in people who had inadequate response to at least one medication, some multi-gene pharmacogenomic tests that include decision support tools are associated with additional costs and QALYs over the 1-year time horizon, and maybe be cost-effective at the willingness-to-pay amount of $100,000 per QALY. Publicly funding multi-gene pharmacogenomic testing in Ontario would result in additional annual costs of between $3.5 million and $16.8 million, with a total budget impact of about $52 million over the next 5 years.People with major depression and caregivers generally supported multi-gene pharmacogenomic testing because they believed it could provide guidance that fit their values. They hoped such guidance would speed symptom relief, would reduce side and help inform their medication choices. Some patients expressed concerns over maintaining confidentiality of test results and the possibility that physicians would sacrifice patient-centred care to follow pharmacogenomic guidance.

Aggression, Impulsivity and Suicidal Behavior in Depressive Disorders: A Comparison Study between New York City (US), Madrid (Spain) and Florence (Italy)

The association of aggression and impulsivity with suicidal behavior (SB) in depression may vary across countries. This study aimed (i) to compare aggression and impulsivity levels, measured with the Brown-Goodwin Scale (BGS) and the Barratt Impulsivity Scale (BIS), respectively, between New York City (NYC) (US), Madrid (Spain) and Florence (Italy) (ANOVA); and (ii) to investigate between-site differences in the association of aggression and impulsivity with previous SB (binary logistic regression). Aggression scores were higher in NYC, followed by Florence and Madrid. Impulsivity levels were higher in Florence than in Madrid or NYC. Aggression and impulsivity scores were higher in suicide attempters than in non-attempters in NYC and in Madrid. SB was associated with aggression in NYC (OR 1.12, 95% CI 1.07–1.16; p < 0.001) and in Florence (OR 1.11, 95% CI 1.01–1.22; p = 0.032). Impulsivity was linked with SB in NYC (OR 1.01, 95% CI 1.00–1.02; p < 0.001) and in Madrid (OR 1.03, 95% CI 1.02–1.05; p < 0.001). The higher suicide rates in NYC, compared to Madrid or Florence, may be, in part, explained by these cross-cultural differences in the contribution of aggression-impulsivity to SB, which should be considered by future research on SB prevention.

[Executive functions and their role in predicting therapeutic response in patients with depressive disorders]

OBJECTIVE

To identify differences in executive functions in patients with depressive disorders depending on their sensitivity to antidepressants.

MATERIAL AND METHODS

The study included 70 patients with depressive disorder. All patients received syndrome-induced psychopharmacotherapy, which included antidepressants and normotimics. The severity of depressive disorder was assessed using the Hamilton Depression Rating Scale (HDRS). The criterion for the effectiveness of therapy (sensitivity) was an improvement in clinical symptoms by 50% or more, as measured with HDRS. The study was performed in two stages (points): at the first point, patients were examined upon admission to the Department before taking medications, and the second point was performed after a 4-week treatment of patients in the hospital. The assessment of executive functions was performed using computer tests Go/Nogo, Corsi and Stroop.

RESULTS AND CONCLUSION

Patients with depressive disorders who were not sensitive to therapy were characterized by low performance in executive functions compared to patients with a positive therapeutic response. Based on the data obtained, a multiple linear regression equation was constructed to predict the therapeutic response based on individual differences in the results of cognitive tests, regardless of potential clinical and demographic factors.

The Effect of Psychiatric History on Pain and Related Outcomes Among Living Kidney Donors

INTRODUCTION

Living donor transplantation of kidneys accounts for one quarter of transplants performed in the United States. Careful screening of psychiatric history is a standard part of the donor evaluation. Little is known about the impact of psychiatric history on post-donation course and pain experience.

RESEARCH QUESTION

This study investigated whether psychiatric history was associated with pain and related outcomes among living kidney donors.

DESIGN

A retrospective medical record review was conducted of 75 living kidney donors who underwent laparoscopic donor nephrectomy. All donor candidates completed a psychological evaluation and were approved for donation by a multidisciplinary committee. History of psychiatric diagnosis and psychiatric medication use were obtained from donors' psychological evaluation reports. Data on pain and related outcomes (ie, history of prescribed pain medication, post-donation pain, opioid use, length of hospital stay, post-donation emergency department visits), as well as demographic and donation-related characteristics were also abstracted from medical records.

RESULTS

Psychiatric history, including current or historical psychiatric diagnosis or psychiatric medication use, in living kidney donors who were evaluated and approved for donation by a transplant psychologist was not associated with greater perceived pain, greater use of opioid pain medication in the post-operative period, longer hospital stays, or more frequent post-donation emergency department visits.

DISCUSSION

The findings demonstrate that carefully screened donors with a psychiatric history have comparable pain-related outcomes as donors without a psychiatric history. This study highlights the importance of the pre-donation psychological evaluation in promoting positive postdonation outcomes through careful selection of donor candidates.

Assessing recurrence of depression using a zero-inflated negative binomial model: A secondary analysis of lifelog data

When studying recurrence of depression, researchers should pay attention to cases where physicians' assessment corresponds to the patients' perception. However, they should also focus on potential signs of recurrence when the recurrence is suspected by the physicians but not the patients (false-negative zeros). Because false negatives can delay diagnosis and treatment, we aimed to investigate "sitting idly" as a predictor influencing no alert sign of recurrence and estimated the counts of recurrence of depression. A smartphone application and a wearable device were used to collect lifelog data from 89 remitted depressive patients over one year. Recurrent depression was defined using the Japanese version of the Kessler Psychological Distress Scale and Patient Health Questionnaire-9 scores. Estimates of the population-averaged parameters indicated that daily hours of sitting idly increased the chances of recurrent depression occurring two to four weeks later. Exposure to daily ultraviolet light reduced depression relapse. Although long sleep was a determinant of zero outcome of the recurrence of depression after two to four weeks, daily hours of sitting idly can negate it. Thus, daily hours of sitting idly could reduce overdispersion of the recurrence of depression, and we could measure recurrent depression accurately by considering changes in sitting idly.

Exploration of GP perspectives on deprescribing antidepressants: a qualitative study

OBJECTIVE

Our aim was to explore general practitioners' (GPs) perceptions and experiences of discontinuing antidepressants.

STUDY DESIGN

A qualitative study using semistructured interviews was undertaken between July 2019 and March 2020. The interviews were transcribed and analysed using a thematic analysis framework.

SETTING

GPs affiliated with a university education and research network for general practice in Ireland.

PARTICIPANTS

A purposive sample of GPs (n=10).

RESULTS

Five themes emerged: shared decision-making; personalised therapy; medication-tapering toolkit; health service factors and concerns around tapering. GPs described being less likely to engage in deprescribing for patients with long-term and/or recurrent depression, older patients and those with comorbidities due to fear of relapse. Access to evidence-based psychological therapies, guidelines, information on rates of relapse, patient leaflets on discontinuing antidepressants and reminder prompts on GP-prescribing software were suggested to optimise appropriate antidepressant discontinuation. There was some suggestion that patients may use antidepressants for longer when talk therapy is not available or taken up.

CONCLUSIONS

GPs are largely confident in their role of managing mild-to-moderate depression and deprescribing antidepressants. This study provides an insight into factors that influence GPs' decisions to deprescribe antidepressants. More information on rates of relapse after discontinuation would be helpful to inform decision-making.

Combined Cognitive-Behavioral Therapy and Placebo Treatment for Patients with Depression: A Follow-Up Assessment

Introduction

A previous study revealed that patients with depression who received a combination of cognitive-behavioral therapy (CBT) and placebo treatment (CBT+placebo) showed greater symptom reduction than a CBT group without a placebo. Moreover, the CBT+placebo group practiced relaxation training more frequently. We conducted a 3-month follow-up assessment to investigate the temporal stability of the placebo effects.

Methods

Eighty-two outpatients with a diagnosis of major depressive disorder who had participated in a 4-week CBT course (CBT: n = 40; CBT with daily placebo treatment: n = 42) returned to a 3-month follow-up assessment. The participants of the CBT+placebo group had been debriefed directly after the course.

Results

Compared to the CBT group, the CBT+placebo group had lower scores on the Beck Depression Inventory-II (BDI-II) at follow-up and more participants were below the clinical cut-off score of the BDI-II. Additionally, the CBT+placebo group continued to practice relaxation more frequently.

Discussion

This study demonstrates that placebo effects are not short-lived and continue to be present after the debriefing.

Nonpharmacological interventions for relapse prevention in unipolar depression: A network meta-analysis

BACKGROUND

The development of prophylactic interventions for major depressive disorder (MDD) is an important issue in clinical practice. We aimed to compare the relative efficacy of nonpharmacological interventions for relapse prevention in adult patients with MDD.

METHODS

Randomized controlled trials investigating nonpharmachological interventions for relapse prevention were included. A Bayesian network meta-analysis was performed. Hazard ratios are reported as effect sizes with 95% credible intervals. Global inconsistency, local inconsistency, heterogeneity, and transitivity were evaluated. Confidence for the results comparing the active treatment with control conditions or antidepressant medicine (ADM) was assessed.

RESULTS

Thirty-six trials were included. Most nonpharmacological interventions were various forms of psychotherapy; others were noninvasive neurostimulation techniques (3 studies with electroconvulsive therapy and 1 study with transcranial magnetic stimulation). Psychotherapy as a monotherapy following ADM or psychotherapy produced significantly better outcomes than control conditions, and there was no significant difference between psychotherapy and ADM. The combination of psychotherapy and ADM was superior to either treatment alone. The results were similar for patients with at least 3 previous episodes. Neurostimulation techniques were also superior to controls, either as a monotherapy or combined with ADM.

CONCLUSIONS

Our study provided evidence that psychotherapy as a monotherapy following ADM or psychotherapy was effective and performed as well as ADM for relapse prevention. Neurostimulation techniques also showed promising results but more studies are needed to confirm their efficacy. These findings may be informative for clinical practice and inspire future research.

On inflammatory hypothesis of depression: what is the role of IL-6 in the middle of the chaos?

Many patients with major depressive disorder (MDD) are reported to have higher levels of multiple inflammatory cytokines including interleukin 6 (IL-6). Recent studies both pre-clinical and clinical have advocated for the functional role of IL-6 in development of MDD and suggested a great potential for targeting this cytokine to open new avenues in pharmacotherapy of depression. The purpose of the present narrative review was to provide an integrated account of how IL-6 may contribute to development of depression. All peer-reviewed journal articles published before July 2020 for each area discussed were searched by WOS, PubMed, MEDLINE, Scopus, Google Scholar, for original research, review articles, and book chapters. Publications between 1980 and July 2020 were included. Alterations in IL-6 levels, both within the periphery and the brain, most probably contribute to depression symptomatology in numerous ways. As IL-6 acts on multiple differing target tissues throughout the body, dysregulation of this particular cytokine can precipitate a multitude of events relevant to depression and blocking its effects can prevent further escalation of inflammatory responses, and potentially pave the way for opening new avenues in diagnosis, treatment, and prevention of this debilitating disorder.

Ketamine and the Future of Rapid-Acting Antidepressants

The therapeutic onset of traditional antidepressants is delayed by several weeks and many depressed patients fail to respond to treatment altogether. In contrast, subanesthetic ketamine can rapidly alleviate symptoms of depression within hours of a single administration, even in patients who are considered treatment-resistant. Ketamine is thought to exert these effects by restoring the integrity of neural circuits that are compromised in depression. This hypothesis stems in part from preclinical observations that ketamine can strengthen synaptic connections by increasing glutamate-mediated neurotransmission and promoting rapid neurotrophic factor release. An improved understanding of how ketamine, and other novel rapid-acting antidepressants, give rise to these processes will help foster future therapeutic innovation. Here, we review the history of antidepressant treatment advances that preceded the ketamine discovery, critically examine mechanistic hypotheses for how ketamine may exert its antidepressant effects, and discuss the impact this knowledge has had on ongoing drug discovery efforts.