Worsening Anxiety, Irritability, Insomnia, or Panic Predicts Poorer Antidepressant Treatment Outcomes: Clinical Utility and Validation of the Concise Associated Symptom Tracking (CAST) Scale

Depression and coronary heart disease: mechanisms, interventions, and treatments

Coronary heart disease (CHD), a cardiovascular condition that poses a significant threat to human health and life, has imposed a substantial economic burden on the world. However, in contrast to conventional risk factors, depression emerges as a novel and independent risk factor for CHD. This condition impacts the onset and progression of CHD and elevates the risk of adverse cardiovascular prognostic events in those already affected by CHD. As a result, depression has garnered increasing global attention. Despite this growing awareness, the specific mechanisms through which depression contributes to the development of CHD remain unclear. Existing research suggests that depression primarily influences the inflammatory response, Hypothalamic-pituitary-adrenocortical axis (HPA) and Autonomic Nervous System (ANS) dysfunction, platelet activation, endothelial dysfunction, lipid metabolism disorders, and genetics, all of which play pivotal roles in CHD development. Furthermore, the effectiveness and safety of antidepressant treatment in CHD patients with comorbid depression and its potential impact on the prognosis of CHD patients have become subjects of controversy. Further investigation is warranted to address these unresolved questions.

The clinical, economic, and patient-centric burden of insomnia symptom severity in adults with major depressive disorder in the United States

INTRODUCTION

Insomnia is prevalent in adults with major depressive disorder (MDD) and is a key diagnostic criterion of MDD; however, little is understood about the burden of insomnia symptom severity in MDD. We evaluated the relationship between insomnia symptom severity and the clinical, economic, and patient-centric burden among community-dwelling individuals with MDD.

METHODS

Respondents with diagnosed depression who reported insomnia symptoms in the past 12 months (N = 4402) were identified from the 2019 United States National Health and Wellness Survey. Multivariable analyses assessed the association of Insomnia Severity Index (ISI) with health-related outcomes while controlling for sociodemographic and health characteristics. Further analyses also controlled for depression severity (9-item Patient Health Questionnaire).

RESULTS

Mean ISI score was 14.3 ± 5.6. Higher ISI was associated with greater depression severity (r = .51, p < .001). After adjustments, a one-standard deviation (5.6-point) increase in ISI score was significantly associated with higher depression (rate ratio [RR] = 1.36), anxiety (RR = 1.33) and daytime sleepiness (RR = 1.16) levels, more healthcare provider (RR = 1.13) and emergency room visits (RR = 1.31), hospitalizations (RR = 1.21), work productivity and activity impairment (RRs = 1.27 and 1.23, respectively), and poorer mental and physical health-related quality of life (β = -3.853 and -1.999, respectively) (p < .001). These findings remained statistically significant when controlling for concurrent depression severity.

CONCLUSION

In adults with MDD, greater insomnia symptom severity is associated with worse health-related outcomes, which suggests the importance of addressing insomnia symptoms as a clinical target for treating MDD.

The Individual and Societal Burden of Treatment-Resistant Depression: An Overview

Major depressive disorder is characterized by depressed mood and/or anhedonia with neurovegetative symptoms and neurocognitive changes affecting an individual's functioning in multiple aspects of life. Treatment outcomes with commonly used antidepressants remain suboptimal. Treatment-resistant depression (TRD) should be considered after inadequate improvement with two or more antidepressant treatments of adequate dose and duration. TRD has been associated with increased disease burden including higher associated costs (both socially and financially) affecting both the individual and society. Additional research is needed to better understand the long-term burden of TRD to both the individual and society.

Psychometric properties of Concise Associated Symptom Tracking (CAST) scale in youths and young adults: Findings from the Texas youth depression and suicide research network (TX-YDSRN)

Symptoms of irritability, anxiety, panic, and insomnia are common in patients with depression, and their worsening after antidepressant treatment initiation is associated with poorer long-term outcomes. The Concise Associated Symptom Tracking (CAST) scale was developed to measure these symptoms in adults with major depressive disorder (MDD). Here, we evaluate the psychometric properties of CAST in an ongoing community-based observational study involving children, adolescents, and young adults. Individuals from the ongoing Texas Youth Depression and Suicide Research Network (TX-YDSRN; N = 952) with CAST data available were included. Fit statistics [Goodness of Fit Index (GFI), Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA)] from confirmatory factor analyses were used to evaluate the five- and four-domain structure of CAST. Item response theory (IRT) analyses were also used. Individuals were grouped based on age (in years) as youths (8-17) and young adults (18-20). Correlations with other clinical measures were used to inform construct validity. Four-domain (irritability, anxiety, panic, and insomnia) 12-item structure of CAST (CAST-12) was optimal for youths (N = 709, GFI = 0.906, CFI = 0.919, RMSEA = 0.095) and young adults (N = 243, GFI = 0.921, CFI = 0.938, RMSEA = 0.0797) with Cronbach's alpha of 0.87 and 0.88, respectively. Slope of each item exceeded 1.0 on IRT analyses suggesting adequate discrimination for each item. Scores on irritability, anxiety, panic, and insomnia were significantly correlated with similar items on other scales. Together these findings suggest that CAST-12 is a valid self-report measure of irritability, anxiety, insomnia, and panic in youths and young adults.

Effects of mindful breathing combined with sleep-inducing exercises in patients with insomnia

BACKGROUND

Insomnia is the most common sleep disorder. It disrupts the patient’s life and work, increases the risk of various health issues, and often requires long-term intervention. The financial burden and inconvenience of treatments discourage patients from complying with them, leading to chronic insomnia.

AIM

To investigate the long-term home-practice effects of mindful breathing combined with a sleep-inducing exercise as adjunctive insomnia therapy.

METHODS

A quasi-experimental design was used in the present work, in which the patients with insomnia were included and grouped based on hospital admission: 40 patients admitted between January and April 2020 were assigned to the control group, and 40 patients admitted between May and August 2020 were assigned to the treatment group. The control group received routine pharmacological and physical therapies, while the treatment group received instruction in mindful breathing and a sleep-inducing exercise in addition to the routine therapies. The Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Insomnia Severity Index (ISI) were utilized to assess sleep-quality improvement in the patient groups before the intervention and at 1 wk, 1 mo, and 3 mo postintervention.

RESULTS

The PSQI, GAD-7, and ISI scores before the intervention and at 1 wk postintervention were not significantly different between the groups. However, compared with the control group, the treatment group exhibited significant improvements in sleep quality, daytime functioning, negative emotions, sleep latency, sleep duration, sleep efficiency, anxiety level, and insomnia severity at 1 and 3 mo postintervention (P < 0.05). The results showed that mindful breathing combined with the sleep-inducing exercise significantly improved the long-term effectiveness of insomnia treatment. At 3 mo, the PSQI scores for the treatment vs the control group were as follows: Sleep quality 0.98 ± 0.48 vs 1.60 ± 0.63, sleep latency 1.98 ± 0.53 vs 2.80 ± 0.41, sleep duration 1.53 ± 0.60 vs 2.70 ± 0.56, sleep efficiency 2.35 ± 0.58 vs 1.63 ± 0.49, sleep disturbance 1.68 ± 0.53 vs 2.35 ± 0.53, hypnotic medication 0.53 ± 0.64 vs 0.93 ± 0.80, and daytime dysfunction 1.43 ± 0.50 vs 2.48 ± 0.51 (all P < 0.05). The GAD-7 scores were 2.75 ± 1.50 vs 7.15 ± 2.28, and the ISI scores were 8.68 ± 2.26 vs 3.38 ± 1.76 for the treatment vs the control group, respectively (all P < 0.05).

CONCLUSION

These simple, cost-effective, and easy-to-implement practices used in clinical or home settings could have profound significance for long-term insomnia treatment and merit wide adoption in clinical practice.

The association of phasic irritability (aggressive outbursts) and tonic irritability (irritable mood) to depression occurrences, symptoms, and subtypes

BACKGROUND

Research among adults has rarely differentiated between tonic irritability (i.e., irritable mood) and phasic irritability (i.e., aggressive outbursts) with respect to multiple dimensions of depression. The current study explored both tonic and phasic irritability in relation to depression severity, depression chronicity, age of depression onset, individual depressive symptom, and depression subtypes.

METHODS

The study included participants (N = 5692) from the National Comorbidity Survey - Replication (NCS-R) part two. The NCS-R used lay-administered, fully standardized diagnostic interviews. The current study implemented linear models, generalized linear models, Cox proportional hazard model, and latent class regression.

RESULTS

Both types of irritability were significantly associated with greater risk for MDD diagnosis, as well as risk for having at least one depressive symptom, early MDE onset, and MDE chronicity. Both phasic and tonic irritability were associated with greater odds of specific depressive symptoms and were differentially related to distinct depressive symptom constellations. Phasic irritability related only to severe depression. Lastly, both phasic and tonic irritability was associated with suicidal ideation, but only phasic irritability was associated with a suicide plan and attempt, above and beyond depression subtypes.

CONCLUSIONS

Both phasic and tonic irritability differentially related to almost all aspects of depression in adults. Specifically, tonic irritability showed overall stronger associations with various depressive features, whereas phasic irritability marked higher depressive severity.

Irritability as an independent predictor of concurrent and future suicidal ideation in adults with stimulant use disorder: Findings from the STRIDE study

BACKGROUND

This report evaluated whether irritability in adults with stimulant use disorder is associated with suicidal ideation (SI) at the same visit (i.e., concurrently) and whether early changes in irritability predict subsequent levels of SI.

METHODS

Adults with stimulant use disorder (n=302) from nine residential addiction treatment programs were included. Participants were randomized to augmentation of usual care with dosed exercise or health education intervention. Irritability, SI, and depression were measured every week with 5-item irritability domain of Concise Associated Symptom Tracking scale, 3-item suicidal thoughts factor of Concise Health Risk Tracking scale, and 16-item Quick Inventory of Depressive Symptomatology Clinician-Rated version (excluding the suicide-related item) respectively during acute-(baseline-to-week-12) and continuation-(week-12-to-week-36) phase. Covariates included age, sex, race, ethnicity, treatment arm, type of substance(s) used, and comorbid psychiatric and medical disorders.

RESULTS

Higher irritability was associated with higher SI concurrently both in the acute-phase: r=0.28 (p<0.0001) and in the continuation-phase: r=0.33 (p<0.0001). Irritability was associated with concurrent SI after controlling for depression [acute-phase: β=0.17 (p<0.0001); continuation-phase: β=0.18 (p<0.0001)]. Greater baseline-to-week-2 reductions in irritability predicted lower levels of SI from week-2-to-week-12 (β=-0.11, p=0.003) and from week-12-to-week-36 (β=-0.22, p<0.0001) after controlling for baseline levels of depression and SI and baseline-to-week-2 changes in depression and SI.

LIMITATIONS

Secondary analyses, self-report measures of irritability and SI, limited generalizability.

CONCLUSIONS

Irritability is associated with SI concurrently, and greater reductions in irritability earlier in treatment are associated with lower levels of subsequent SI. Therefore, targeting irritability may reduce suicidality in adults with stimulant use disorder.

Preventing Irritability and Temper Outbursts in Youth by Building Resilience

Severe irritability and temper outbursts are risk factors for the onset of serious and lifelong mood disorders. In treating children and adolescents with severe irritability, clinicians should evaluate and address safety issues before acute stabilization of symptoms. Then, clinicians can initiate interventions to prevent the onset or relapses of the undesired behavior and its functional consequences. This review summarizes primary, secondary, and tertiary relapse prevention strategies, with an emphasis on strategies that build resilience in youth that mitigate the onset, recurrence, and progression of emotion dysregulation.

Anger attacks are associated with persistently elevated irritability in MDD: findings from the EMBARC study

BACKGROUND

This report tests the association of self-reported symptoms of irritability with overt behavior of anger attacks (uncharacteristic sudden bouts of anger that are disproportionate to situation and associated with autonomic activation).

METHODS

Participants of the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care study who completed Massachusetts General Hospital Anger Attacks questionnaire were included (n = 293). At each visit, the 17-item Hamilton Depression Rating Scale and the 16-item Concise Associated Symptom Tracking scale were used to measure depression, anxiety, and irritability. In those with anger attacks present v. those without anger attacks, separate t tests and mixed model analyses compared afore-mentioned symptoms at baseline and changes with treatment respectively. As anger attacks may occur without aggressive behaviors, analyses were repeated based only on the presence of aggressive behaviors.

RESULTS

At baseline, those with anger attacks (n = 109) v. those without anger attacks (n = 184) had similar levels of depression but higher levels of irritability [effect size (d) = 0.80] and anxiety (d = 0.32). With acute-phase treatment, participants with anger attacks experienced a greater reduction in irritability (p < 0.001) but not in depression (p = 0.813) or anxiety (p = 0.771) as compared to those without anger attacks. Yet, irritability levels at week-8 were higher in those with anger attacks (d = 0.32) than those without anger attacks. Similar results were found in participants with aggressive behaviors.

CONCLUSIONS

The presence of anger attacks in outpatients with major depressive disorder may identify a sub-group of patients with persistently elevated irritability.

Do side effects of antidepressants impact efficacy estimates based on the Hamilton Depression Rating Scale? A pooled patient-level analysis

The Hamilton Depression Rating Scale (HDRS-17) measures symptoms that may overlap with common antidepressant side effects (e.g., sexual dysfunction), thus making it possible that side effects of antidepressant treatment are erroneously rated as symptoms of depression, and vice versa. This study uses patient-level data from previously conducted antidepressant treatment trials to assess whether side effect ratings co-vary with HDRS-17 ratings. Data from all HDRS-17-rated, industry-sponsored pre- and post-marketing trials (n = 4647) comparing the serotonin and noradrenaline reuptake inhibitor, duloxetine, to placebo and/or to a selective serotonin reuptake inhibitor were pooled; three studies, which utilised sub-therapeutic doses, did not have symptom-level ratings available and could not be included. Severity was assessed for side effects related to sleep, somatic anxiety, gastrointestinal function, and sexual dysfunction. Analysis of covariance was used to assess the relation between these side effects and ratings of relevant HDRS-17-derived outcome parameters. Side effects related to sleep, somatic anxiety and sexual dysfunction significantly and exclusively associated with higher scores on HDRS-17 items measuring the corresponding domains. Side effects related to gastrointestinal function associated with higher HDRS-17 item scores on all assessed domains. Treatment outcome was significantly related to side effect severity when assessed using HDRS-17-sum (beta 0.32 (0.074), p < 0.001), but not when the HDRS-6-sum-score (beta 0.035 (0.043), p = 0.415) or the depressed mood item (beta 0.007 (0.012), p = .527) were used as effect parameters. That some HDRS-17 items co-vary with common antidepressant side effects suggests some of these adverse events are counted twice, potentially leading to an underestimation of antidepressant efficacy.

Cross-Sectional Associations Among Symptoms of Pain, Irritability, and Depression and How These Symptoms Relate to Social Functioning and Quality of Life: Findings From the EMBARC and STRIDE Studies and the VitalSign6 Project

OBJECTIVE

The aim of this report was to evaluate the psychometric properties of the Pain Frequency, Intensity, and Burden Scale (P-FIBS), a brief measure of pain, as well as the association of pain with irritability and depression and how these symptoms relate to functional impairments.

METHODS

Participants of 2 randomized controlled trials (Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care [EMBARC; n = 251 with DSM-IV diagnosis of major depressive disorder; study duration: August 2011-December 2015] and STimulant Reduction Intervention Using Dosed Exercise [STRIDE; n = 302 with DSM-IV diagnosis of stimulant abuse or dependence; study-duration: July 2010-February 2013]) and treatment-seeking patients in primary care clinics from an ongoing quality-improvement project (VitalSign6; n = 4,370; project duration: August 2014-July 2019) were included. Psychometric properties of the P-FIBS were evaluated with confirmatory factor and item response theory analyses in EMBARC and VitalSign6. The approach of Baron and Kenny was used to assess whether irritability accounted for the effect of pain on depression.

RESULTS

Cronbach α (0.84-0.89) and model fits for single-factor structure of P-FIBS were acceptable. Pain was positively correlated with irritability (r = 0.22-0.29) and depression (r = 0.10-0.33). Irritability accounted for 40.7%-65.5% of the effect of pain on depression. Higher irritability and depression were associated with poorer social functioning, quality of life, and productivity in work- and non-work-related activities. Pain was associated with non-work-related activity impairments even after controlling for irritability and depression.

CONCLUSIONS

The P-FIBS is a brief and reliable measure of pain. Irritability is associated with pain and accounts for a large proportion of the effect of pain on depression. Symptoms of pain, irritability, and depression are associated with functional impairments.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT01407094 (EMBARC), NCT01141608 (STRIDE).

What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications

Although psychiatric drug withdrawal syndromes have been recognized since the 1950s - recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% - medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.

Differential response to SSRI versus Placebo and distinct neural signatures among data-driven subgroups of patients with major depressive disorder

OBJECTIVE

To identify data-driven subgroups in Major Depressive Disorder (MDD) in order to elucidate underlying neural correlates and determine if these subgroups have utility in predicting response to antidepressant versus placebo.

METHODS

Using 27 clinical measures at baseline of Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care for Depression (EMBARC) study, participants with MDD (n=244) were sub grouped using principal component (PC) analysis. Baseline-to-week-8 changes in depression severity with sertraline versus placebo were compared in these subgroups. Resting-state functional connectivity of these subgroups were compared to those of healthy controls (n=38).

RESULTS

Eight subgroups were identified from four PCs: (PC1) severity of depression-associated symptoms, (PC2) sub-threshold mania and anhedonia, (PC3) childhood trauma, medical comorbidities, and sexual dysfunction, and (PC4) personality traits of openness and agreeableness. Participants with high childhood trauma experienced greater improvement with sertraline (Cohen's d=0.87), whereas those with either higher levels of subthreshold hypomanic symptoms (Cohen's d=0.67) or with lower levels of agreeableness and openness experienced greater improvement with placebo (Cohen's d=0.71). Participants with high childhood trauma had greater connectivity between salience and dorsal attention networks, whereas those with higher levels of subthreshold hypomanic symptoms and lower levels of agreeableness and openness had greater connectivity within limbic network and that of visual network with hippocampus and dorsal attention network.

CONCLUSION

Assessing history of childhood trauma, presence of subthreshold hypomanic symptoms and personality traits may help to identify subgroups of patients with MDD who respond differentially to sertraline or placebo and have distinct neural signatures.

Spotlight on Pimavanserin Tartrate and Its Therapeutic Potential in the Treatment of Major Depressive Disorder: The Evidence to Date

Major depressive disorder (MDD) is widely prevalent and one of the leading causes of disability. Treatment outcomes remain suboptimal with 1 in 3 patients with MDD responding inadequately to commonly used antidepressants. Pimavanserin, an atypical antipsychotic that modulates serotonergic neurotransmission by selectively binding to serotonin receptor (2A and 2C) subtypes and without dopaminergic activity, may have the potential as an adjunctive treatment for MDD. In a phase 2 trial (n=203), addition of pimavanserin, as compared to placebo, to stable treatment with antidepressants was associated with greater reduction in 17-item Hamilton Depression Rating Scale score [HAMD, least square means (95% confidence interval) of -1.7 (-0.03, -3.37), p=0.039]. Furthermore, treatment with pimavanserin was associated with significantly greater improvement in specific symptoms associated with depression such as impaired sexual function, anxiety, sleepiness, and irritability. However, the availability of pimavanserin for clinical care of patients with MDD remains uncertain. Top-line results of phase 3 studies (n=298) that were announced by the sponsor found similar reductions in HAMD (mean baseline-to-week-5 reduction of 9.0 and 8.1, p=0.296) and rates of adverse events (58.1% and 54.7%) with addition of pimavanserin and placebo respectively to stable treatment with antidepressants. Given the potential benefit for specific symptoms such as impaired sexual function, anxiety and sleep/wakefulness disturbances, future studies that enrich for these symptoms may be needed to clarify the utility of adjunctive pimavanserin in treatment of patients with MDD.

Association of anger attacks with suicidal ideation in adults with major depressive disorder: Findings from the EMBARC study

BACKGROUND

This report evaluates whether anger attacks (sudden uncharacteristic bouts of anger that are associated with autonomic arousal and/or aggression) in patients with major depressive disorder (MDD) are associated with elevated suicidal ideation (SI; active suicidal thoughts and plans).

METHODS

Participants of Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study who completed Massachusetts General Hospital Anger Attack Questionnaire (AAQ) at baseline were included (n = 293). Levels of SI (suicidal thoughts factor of Concise Health Risk Tracking) were compared at baseline with generalized linear models, and during Stage 1 (baseline-to-week-8) and Stage 2 (week-8-to-week-16) with repeated-measures mixed model analyses. Covariates included age, sex, race, ethnicity, site, and treatment arm.

RESULTS

At baseline, participants with (n = 109) versus without anger attacks (n = 184) had higher levels of SI (Cohen's d effect size [d] = 1.20). Those with ≥9 anger attacks in the past month had significantly higher SI than those with 1-2 (d = 1.21), 3-4 (d = 1.48), and 5-8 (d = 0.94) anger attacks in the past month. Furthermore, participants with anger attacks at baseline reported higher SI at each post-baseline visit (both Stages 1 and 2) of EMBARC study (d = 0.39-0.77; all p < .05). Associations between anger attacks and SI were significant even after controlling for irritability, hostility, anxious arousal, depression, suicide propensity, and self-reported pain at baseline and lifetime suicidal tendencies. Similar results were found in participants with aggressive behaviors.

CONCLUSION

Anger attacks in outpatients with MDD may be associated with chronically elevated SI.   Clinical Trials Registration: Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care for Depression (EMBARC); NCT01407094; https://clinicaltrials.gov/ct2/show/NCT01407094.

Association between irritability and suicidal ideation in three clinical trials of adults with major depressive disorder

Irritability in pediatric samples is associated with higher rates of subsequent suicide-related outcomes. No study, to date, has evaluated the longitudinal association between irritability and suicidal ideation (SI) in adults with major depressive disorder (MDD). This report evaluated whether irritability is associated with SI at the same visit (i.e., concurrently) and whether early changes in irritability with antidepressant treatment predict subsequent levels of SI. Participants of Combining Medications to Enhance Depression Outcomes (CO-MED, n = 665), Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC, n = 296), and Suicide Assessment Methodology Study (SAMS, n = 266) were included. Repeated-measures mixed model analyses evaluated concurrent association throughout the trial between irritability (five-item irritability domain of Concise Associated Symptom Tracking scale) and SI (three-item suicidal thoughts factor of Concise Health Risk Tracking scale) after controlling for overall depression (excluding suicidality-related item), and predicted subsequent levels of SI (repeated observations from week-2-to-week-8) based on early (baseline-to-week-2) changes in irritability after controlling for early changes in overall depression. Higher irritability was associated with higher SI concurrently; estimates (standard error) were 0.18 (0.02, p < 0.0001), 0.64 (0.02, p < 0.0001), and 0.26 (0.04, p < 0.0001) in CO-MED, EMBARC, and SAMS respectively. Greater baseline-to-week-2 reductions in irritability predicted lower levels of subsequent SI; estimates (standard errors) were -0.08 (0.03, p = 0.023), -0.50 (0.05, p < 0.0001), and -0.12 (0.05, p = 0.024) in CO-MED, EMBARC, and SAMS, respectively. Controlling for anxiety or insomnia produced similar results. In conclusion, irritability and SI were consistently linked in adults with MDD. These findings support careful assessment of irritability in suicide risk assessment.

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

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

Improvements in irritability with sertraline versus placebo: Findings from the EMBARC study

BACKGROUND

This report seeks to evaluate improvements in symptoms of irritability with sertraline (a selective serotonin reuptake inhibitor antidepressant) versus placebo.

METHODS

Participants of Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study who were randomized to 8 weeks of treatment with either sertraline or placebo and completed 5-item irritability domain of Concise Associated Symptom Tracking scale (CAST-IRR) at baseline were included (n = 292). Repeated measures mixed model analysis with CAST-IRR as the outcome variable and treatment arm-by-time interaction as the independent variable of interest evaluated whether changes in irritability with treatment differed between sertraline and placebo arms. A separate analysis controlled for levels of overall depression severity (17-item Hamilton Depression Rating Scale). Covariates included age, sex, race, ethnicity, and site.

RESULTS

There was a significant treatment arm-by-time interaction (F = 6.96, df = 6, 1418, p <0.0001) suggesting that changes in irritability with sertraline differed from placebo. The magnitude of reduction in irritability from baseline to week-8 was greater with sertraline than with placebo (Cohen's d effect size = 0.56). After controlling for levels of overall depression severity at each visit, reduction in irritability with time continued to be significant with sertraline but not with placebo.

LIMITATIONS

Secondary analysis, limited generalizability, lack of non-serotonergic antidepressants.

DISCUSSION

There is greater improvement in irritability with sertraline than with placebo. Improvement in irritability with sertraline was independent of its effects on overall depression severity. CLINICALTRIALS.

GOV IDENTIFIER

NCT01407094.

VitalSign6: A Primary Care First (PCP-First) Model for Universal Screening and Measurement-Based Care for Depression

Major depressive disorder affects one in five adults in the United States. While practice guidelines recommend universal screening for depression in primary care settings, clinical outcomes suffer in the absence of optimal models to manage those who screen positive for depression. The current practice of employing additional mental health professionals perpetuates the assumption that primary care providers (PCP) cannot effectively manage depression, which is not feasible, due to the added costs and shortage of mental health professionals. We have extended our previous work, which demonstrated similar treatment outcomes for depression in primary care and psychiatric settings, using measurement-based care (MBC) by developing a model, called Primary Care First (PCP-First), that empowers PCPs to effectively manage depression in their patients. This model incorporates health information technology tools, through an electronic health records (EHR) integrated web-application and facilitates the following five components: (1) Screening (2) diagnosis (3) treatment selection (4) treatment implementation and (5) treatment revision. We have implemented this model as part of a quality improvement project, called VitalSign⁶, and will measure its success using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. In this report, we provide the background and rationale of the PCP-First model and the operationalization of VitalSign⁶ project.

Screening and Management of Depression in Patients With Cardiovascular Disease: JACC State-of-the-Art Review

Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.