Measuring psychotic depression

Treatment of schizophrenia evaluated via the pharmacopsychometric triangle-An integrative approach with emphasis on well-being and functioning

Quantification of treatment response is crucial to optimize outcomes for patients with schizophrenia. In this study, we evaluated the relationship between quantitative measures of clinician-rated symptom severity and self-rated side effects, well-being, and functioning among inpatients with schizophrenia using the six-item version of the Positive and Negative Syndrome Scale (PANSS-6), the Glasgow Antipsychotic Side-effect Scale (GASS), the WHO-Five Well-being Index (WHO-5), and the Sheehan Disability Scale (SDS). All measurements were conducted as close to admission and discharge as possible. Well-being and functioning were found to be most strongly associated with the additive effect of symptoms and side effects, while changes in side effects, well-being, and functioning appeared to be relatively independent from changes in symptom severity. The use of both symptom and side effect measures should inform clinical decision-making in the treatment of schizophrenia, as it has the potential to optimize functioning and well-being.

A Machine-Learning-Algorithm-Based Prediction Model for Psychotic Symptoms in Patients with Depressive Disorder

Psychotic symptoms are rarely concurrent with the clinical manifestations of depression. Additionally, whether psychotic major depression is a subtype of major depression or a clinical syndrome distinct from non-psychotic major depression remains controversial. Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants, we developed a machine-learning-algorithm-based prediction model for concurrent psychotic symptoms in patients with depressive disorders. The advantages of machine learning algorithms include the easy identification of trends and patterns, handling of multi-dimensional and multi-faceted data, and wide application. Among 1171 patients with depressive disorders, those with psychotic symptoms were characterized by significantly higher rates of depressed mood, loss of interest and enjoyment, reduced energy and diminished activity, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, psychomotor agitation or retardation, disturbed sleep, diminished appetite, and greater proportions of moderate and severe degrees of depression compared to patients without psychotic symptoms. The area under the curve was 0.823. The overall accuracy was 0.931 (95% confidence interval: 0.897–0.956). Severe depression (degree of depression) was the most important variable in the prediction model, followed by diminished appetite, subthreshold (degree of depression), ideas or acts of self-harm or suicide, outpatient status, age, psychomotor retardation or agitation, and others. In conclusion, the machine-learning-based model predicted concurrent psychotic symptoms in patients with major depression in connection with the “severity psychosis” hypothesis.

Mental depression: Relation to different disease status, newer treatments and its association with COVID-19 pandemic (Review)

The present study aimed to review major depression, including its types, epidemiology, association with different diseases status and treatments, as well as its correlation with the current COVID-19 pandemic. Mental depression is a common disorder that affects most individuals at one time or another. During depression, there are changes in mood and behavior, accompanied by feelings of defeat, hopelessness, or even suicidal thoughts. Depression has a direct or indirect relation with a number of other diseases including Alzheimer's disease, stroke, epilepsy, diabetes, cardiovascular disease and cancer. In addition, antidepressant drugs have several side effects including sedation, increased weight, indigestion, sexual dysfunction, or a decrease in blood pressure. Stopping medication may cause a relapse of the symptoms of depression and pose a risk of attempted suicide. The pandemic of COVID-19 has affected the mental health of individuals, including patients, individuals contacting patients and medical staff with a number of mental disorders that may adversely affect the immune ability of their bodies. Some of the drugs currently included in the protocols for treating COVID-19 may negatively affect the mental health of patients. Evidence accumulated over the years indicates that serotonin (5HT) deficiencies and norepinephrine (NE) in the brain can lead to mental depression. Drugs that increase levels of NE and 5HT are commonly used in the treatment of depression. The common reason for mood disorders, including mania and bipolar disease are not clearly understood. It is assumed that hyperactivity in specific parts of the brain and excessive activity of neurotransmitters may be involved. Early diagnosis and developing new treatment strategies are essential for the prevention of the severe consequences of depression. In addition, extensive research should be directed towards the investigation of the mental health disturbances occurring during and/or after COVID-19 infection. This may lead to the incorporation of a suitable antidepressant into the current treatment protocols.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

Validity and Reliability of the Self-administered Psycho-TherApy-SystemS (SELFPASS) Item Pool for the Daily Mood Tracking of Depressive Symptoms: Cross-sectional Web-Based Survey

BACKGROUND

e-Mental health apps targeting depression have gained increased attention in mental health care. Daily self-assessment is an essential part of e-mental health apps. The Self-administered Psycho-TherApy-SystemS (SELFPASS) app is a self-management app to manage depressive and comorbid anxiety symptoms of patients with a depression diagnosis. A self-developed item pool with 40 depression items and 12 anxiety items is included to provide symptom-specific suggestions for interventions. However, the psychometric properties of the item pool have not yet been evaluated.

OBJECTIVE

The aim of this study is to investigate the validity and reliability of the SELFPASS item pool.

METHODS

A weblink with the SELFPASS item pool and validated mood assessment scales was distributed to healthy subjects and patients who had received a diagnosis of a depressive disorder within the last year. Two scores were derived from the SELFPASS item pool: SELFPASS depression (SP-D) and SELFPASS anxiety (SP-A). Reliability was examined using Cronbach α. Construct validity was assessed through Pearson correlations with the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder Scale-7 (GAD-7), and the WHO-5-Wellbeing-Scale (WHO-5). Logistic regression analysis was performed as an indicator for concurrent criterion validity of SP-D and SP-A. Factor analysis was performed to provide information about the underlying factor structure of the item pool. Item-scale correlations were calculated in order to determine item quality.

RESULTS

A total of 284 participants were included, with 192 (67.6%) healthy subjects and 92 (32.4%) patients. Cronbach α was set to .94 for SP-D and α=.88 for SP-A. We found significant positive correlations between SP-D and PHQ-9 scores (r=0.87; P<.001) and between SP-A and GAD-7 scores (r=0.80; P<.001), and negative correlations between SP-D and WHO-5 scores (r=-0.80; P<.001) and between SP-A and WHO-5 scores (r=-0.69; P<.001). Increasing scores of SP-D and SP-A led to increased odds of belonging to the patient group (SP-D: odds ratio 1.03, 95% CI 1.01-1.05; P<.001; SP-A: 1.05, 1.05-1.01; P=.01). The item pool yielded 2 factors: one that consisted of mood-related items and another with somatic-related items.

CONCLUSIONS

The SELFPASS item pool showed good psychometric properties in terms of reliability, construct, and criterion validity. The item pool is an appropriate source for daily mood tracking in future e-mental health apps among patients with depression. Our study provides general recommendations for future developments as well as recommendations within the item pool.

Cross-cultural evaluation of the French version of the Delusion Assessment Scale (DAS) and Psychotic Depression Assessment Scale (PDAS)

BACKGROUND

Major depressive disorder with psychotic features (MDDPsy), compared to nonpsychotic MDD, involves an increased risk of suicide and failure to achieve treatment response. Symptom scales can be useful to assess patients with MDDPsy. The aim of the present study was to validate French versions of the Delusion Assessment Scale (DAS) and Psychotic Depression Assessment Scale (PDAS).

METHODS

One hundred patients were included. The scales were filled out by psychiatrists. Data from participants who accepted a second interview were used for inter-judge reliability. The scalability and psychometric properties of both scales were assessed.

RESULTS

Data from 94 patients were used. Owing to low score variability between patients, the predefined threshold for scalability (≥0.40) was not reached for both scales. Factorial analysis of the DAS identified five factors, different from those of the original version. Five factors were also identified in the PDAS, of which two comprised items from the HDRS and the other three items from the BPRS. Floor and ceiling effects were observed in both scales, due in part to the construction of certain subscales. Unlike the PDAS, the DAS had good internal consistency. Multiple correlations were observed between the DAS dimensions but none between those of the PDAS. Both scales showed good inter-judge reliability. Convergent validity analyses showed correlations with HDRS, BPRS and CGI.

LIMITATIONS

Inter-judge reliability was calculated from a relatively small number of volunteers.

CONCLUSIONS

The good psychometric properties of the French versions of the DAS and PDAS could help in assessing MDDPsy, in particular its psychotic features, and hence improve response to treatment and prognosis.

Psychotic depression in hospitalized patients: Longitudinal outcomes of psychotic vs. nonpsychotic depression among inpatients

Even though psychotic depression is related to worse outcomes than nonpsychotic depression, there is increasing evidence that this greater severity is not solely explained by the depressive symptoms. We evaluated the socio-demographic and clinical characteristics, as well as the differences in clinical outcomes of psychiatric hospitalization between psychotic and non-psychotic depression. Two-hundred-eighty-eight depressive inpatients were assessed within 72 h after hospitalization and 24 h before discharge. We compared scores of Hamilton Depression Rating Scale 17-items (HDRS-17), Clinical Global Impression (CGI), Brief Psychiatric Rating Scale (BPRS), and Global Assessment of Functioning (GAF) between psychotic and nonpsychotic patients. Instruments were compared both cross-sectionally - on admission and discharge - and longitudinally. Longitudinal outcomes were corrected for potential confounders (sex, age, age at disease onset, years of study, previous history of mania/hypomania, electroconvulsive therapy in current hospitalization, history of attempted suicide, number of suicide attempts, and previous hospitalizations). One-hundred-thirty-one depressive inpatients (45.4%) presented psychotic features. Both groups showed similar HDRS-17 scores at admission and discharge. However, psychotic patients had worse scores on BPRS, CGI, and GAF at both timepoints. Both groups had similar improvement on HDRS-17 (P = 0.75), CGI (P = 0.5), and GAF (P = 0.84), but psychotic patients had greater improvement on BPRS (P < 0.001). Psychotic inpatients showed worse clinical and functional parameters. Nonetheless, the groups did not differ in depressive symptom severity. These findings reinforce the hypothesis that depressive episode with psychotic features is a more severe form of the disease irrespective of intensity of affective symptomatology.

Electroconvulsive therapy (ECT) for moderate-severity major depression among the elderly: Data from the pride study

BACKGROUND

Electroconvulsive therapy (ECT) is usually reserved for treatment of severe major depressive disorder (MDD), but may be equally effective in the treatment of moderate-severity MDD. This possibility, however, has only been studied to a very limited extent. We therefore investigated the efficacy of ECT after stratifying patients into severe MDD and moderate-severity MDD.

METHODS

We used data from the Prolonging Remission in Depressed Elderly (PRIDE) study, in which 240 patients (≥60 years) with MDD were treated with right unilateral ultrabrief pulse ECT, combined with venlafaxine. We used the six-item core depression subscale (HAM-D₆) of the Hamilton Depression Rating Scale to define depression severity. Participants with baseline total scores ≥12 on the HAM-D₆ were considered to have severe MDD, while those with HAM-D₆ total scores <12 were considered to have moderate-severity MDD.

RESULTS

Among the participants with severe MDD and moderate-severity MDD, the mean change in the HAM-D₆ total score from baseline to endpoint was -8.2 (95% confidence interval (95%CI) = -7.5; -9.0, paired t-test: p < 0.001) and -5.9 (95%CI = -5.1; -6.6, paired t-test: p < 0.001), respectively. A total of 63% of those with severe MDD and 75% of those with moderate-severity MDD achieved remission (HAM-D₆ total score ≤4) (Pearson's 2-sample chi-squared test of difference between groups: p = 0.27).

LIMITATIONS

The PRIDE study was not designed to address this research question.

CONCLUSIONS

ECT combined with venlafaxine appears to be an effective treatment for moderate-severity MDD. It may be appropriate to expand the indications for ECT to include patients with moderate-severity MDD.

Thyroid hormone treatment in the management of treatment-resistant unipolar depression: a systematic review and meta-analysis

BACKGROUND

Treatment with thyroid hormones is occasionally used in the management of treatment-resistant depression. However, the evidence supporting this treatment is not fully established. The aim of this study was to systematically review the literature on the effect of adjunctive thyroid hormone in the management of treatment-resistant unipolar depression and to provide a pooled estimate of its efficacy.

METHODS

The study is registered with PROSPERO (reg. no. CRD42018108088) and followed the PRISMA guidelines. Searches were carried out on June 24, 2019, in PubMed, EMBASE, and PsycINFO. Each record was screened independently by at least two reviewers. In instances of discrepancies, consensus was reached upon discussion. Pooled efficacy estimates were calculated based on response rates (decrease of ≥50% on the primary outcome measure) using random effect statistics.

RESULTS

The search yielded 1355 records. Based on the screening of these records, we identified 10 studies that met the inclusion criteria (total number of patients = 663). The comparison of response to thyroid hormones vs. placebo resulted in an odds ratio of 1.56 (95% CI: 0.50-4.84). Similarly, the comparison of response to thyroid hormones vs. lithium resulted in an odds ratio of 1.91 (95% CI: 0.85-4.26). Thus, adjunctive therapy with thyroid hormones was not superior to placebo or lithium in the management of treatment-resistant unipolar depression.

CONCLUSION

According to this review and meta-analysis, there is not sufficient evidence to support the use of adjunctive thyroid hormones for treatment-resistant unipolar depression.

Cognitive Deficits in Older Adults With Psychotic Depression: A Meta-Analysis

A major depressive disorder with psychotic features, that is, psychotic depression (PD), is often accompanied by cognitive deficits, particularly in older patients. We aimed to assess to what extent various cognitive domains are affected in older patients with PD compared to those with nonpsychotic depression (NPD). Therefore, a systematic search was conducted in Medline, Embase, Web of Science, the Cumulative Index to Nursing and Allied Literature (CINAHL), Google Scholar, and Cochrane for all relevant studies. Hereafter, we conducted a meta-analysis of seven studies on cognitive deficits in older adults (55+ years), comparing patients with PD and patients with NPD. Compared to patients with NPD, those with PD not only showed a significantly poorer performance on overall cognitive function, with a Hedges' g effect size of -0.34 (95% confidence interval: -0.56; -0.12; p = 0.003), but also on nearly all separate cognitive domains, with Hedges' g effect sizes ranging from -0.26 to -0.64 (all p's <0.003), of which attention was most adversely affected. Verbal fluency showed no significant effect, although this analysis may have been underpowered. The funnel plot suggested no significant publication bias (Egger test intercept: -2.47; 95% confidence interval: -5.50; 0.55; p = 0.09). We conclude that older patients with PD show more cognitive deficits on all cognitive domains, except for verbal fluency, compared to patients with NPD. It is crucial that clinicians and researchers take cognitive deficits into consideration in older adults with PD.

Diagnostic Issues of Depressive Disorders from Kraepelinian Dualism to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Because the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) was mainly influenced by the neo-Kraepelinian approach, its categorical approach to defining mental disorders has been criticized from the viewpoint of etiological neutrality. In the context of bridging the gap between "presumed etiologies-based symptomatology" and "identifiable pathophysiological etiologies," the content in 5th edition, the DSM-5, has been revised to incorporate a combination of categorical and dimensional approaches. The most remarkable change of note regarding the diagnostic classification of depressive disorders in the DSM-5 is the splitting of mood disorders into bipolar disorders and depressive disorders, which is in accordance with the deconstruction of the Kraepelinian dualism for psychoses. The transdiagnostic specifiers "with mixed features," "with psychotic features," and "with anxious distress" are introduced to describe the relationships of depressive disorders with bipolar disorders, schizophrenia, and generalized anxiety disorder, respectively, in a dimensional manner. The lowering of the diagnostic threshold for major depressive disorder (MDD) may be caused by the addition of "hopelessness" to the subjective descriptors of depressive mood and the elimination of "bereavement exclusion" from the definition of MDD. Since the heterogeneity of MDD is equivalent to the Wittgensteinian "games" analogy, the different types of MDD are related not by a single essential feature but rather by "family resemblance." Network analyses of MDD symptoms may therefore need further review to elucidate the connections among interrelated symptoms and other clinical elements.

Assessment of the psychometric properties of the 17- and 6-item Hamilton Depression Rating Scales in major depressive disorder, bipolar depression and bipolar depression with mixed features

Assessing therapeutic response in depression requires scales that adequately measure the core symptoms of depressive symptomatology. The main goal of this study was to assess the psychometric properties of the 17-item Hamilton Depression Rating Scale (HAM-D17) and the 6-item Hamilton Depression Rating Scale (HAM-D6) in patients with Major Depressive Disorder (MDD), bipolar depression and bipolar depression with mixed features. We conducted a reanalysis of a pragmatic clinical trial in an outpatient clinic for mood disorders that included eight weeks of follow-up. A Mokken analysis was performed to evaluate the unidimensionality of the HAM-D17 and HAM-D6, and the Spearman correlation was used to assess concurrent validity between the HAM-D17, the HAM-D6 and quality of life scale (SF-36 and WHOQOL-BREF) scores. A total of 237 patients with a mean age of 40.2 years (±11.7) were included. According to the DSM-IV criteria, 58 (24.5%) were diagnosed with MDD and 73 (30.8%) were diagnosed with bipolar depression. Bipolar depression with mixed features was diagnosed in 106 (44.7%) patients according to the DSM-IV and supplemented by the Cincinnati criteria. Only the HAM-D6 scale proved to be unidimensional, showing strong homogeneity for evaluating MDD, moderate homogeneity for bipolar depression and weak homogeneity for bipolar depression with mixed features. Both the HAM-D17 and the HAM-D6 had inverse, significant correlations at baseline with SF-36 and WHOQOL-BREF scores. This is the first study to include bipolar depression patients with mixed features in an assessment of HAM-D6 unidimensionality.

The validity and sensitivity of PANSS-6 in treatment-resistant schizophrenia

OBJECTIVE

To test the validity and sensitivity of the six-item version (PANSS-6) of the 30-item Positive and Negative Syndrome Scale (PANSS-30) in treatment-resistant schizophrenia (TRS).

METHOD

Using data from the clozapine phase (2E) of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, we investigated the following: (i) The scalability of PANSS-6 and PANSS-30; (ii) The correlation between PANSS-6 and PANSS-30 total scores; (iii) Whether PANSS-6 could identify cross-sectional symptom remission; and (iv) The efficacy of clozapine, olanzapine, risperidone and quetiapine in TRS using the 'speed of change' on PANSS-6 and PANSS-30 (change in total score per week) as outcome measures.

RESULTS

We found that (i) only PANSS-6 and not PANSS-30 was scalable; (ii) The correlation between PANSS-6 and PANSS-30 total scores was high (Spearman coefficient: 0.85), (iii) PANSS-6 accurately identified cross-sectional symptom remission as defined by the Andreasen et al. criteria; and (iv) The only antipsychotic that caused improvement (speed of change significantly lower than 0 during the first three months of treatment) was clozapine, both when using PANSS-6 (speed of change: -0.50 points/week; 95%CI: -0.84, -0.17) and PANSS-30 (speed of change: -1.41 points/week; 95%CI: -2.80, -0.02) as outcome measures.

CONCLUSION

PANSS-6 validly measures severity, remission and antipsychotic efficacy in TRS.

Clinical validation of the Psychotic Depression Assessment Scale (PDAS) against independent global severity ratings in older adults

OBJECTIVES

According to a recent study, ratings on the Psychotic Depression Assessment Scale (PDAS) obtained via a dedicated semi-structured interview are valid measures of the severity of psychotic depression. This study aimed to further test the validity, scalability and responsiveness of the PDAS in older adults using independent ratings on the Clinical Global Impression Scale - Severity (CGI-S) and the Montgomery-Asberg Depression Rating Scale (MADRS) as references.

METHODS

Ratings were performed at admission and discharge at two old age psychiatric wards in Flanders, Belgium. In total, 62 older adults (mean age: 74.3 years) with psychotic depression were included. The PDAS was rated by trained nurses using the semi-structured PDAS interview. Senior psychiatrists scored the participants on the CGI-S. Psychologists or experienced nurses rated participants on the MADRS. Clinical validity was assessed by correlating the PDAS total scores with CGI-S ratings and MADRS total scores. Mokken analysis was performed to assess the scalability of the PDAS. Responsiveness was assessed by comparing the proportion of participants in remission (PDAS total score <8 at study baseline and endpoint).

RESULTS

The Spearman correlation coefficients were 0.76 and 0.79 for the PDAS versus CGI-S and PDAS versus MADRS, respectively. The Mokken analysis yielded a Loevinger coefficient of 0.46, which is indicative of scalability. At admission, no participants met the PDAS remission criterion. At discharge, 54% (95% confidence interval: 47%-60%) of the patients met this criterion.

CONCLUSION

The PDAS appears to be a clinically valid, scalable and responsive measure of the severity of psychotic depression in older adults.

Validation of the semi-structured Psychotic Depression Assessment Scale (PDAS) interview

OBJECTIVE

Recently, a semi-structured interview dedicated to aid rating on the Psychotic Depression Assessment Scale (PDAS) was developed. Here, we aimed to validate PDAS ratings collected via this semi-structured interview.

METHODS

A total of 50 patients with psychotic depression - 34 with unipolar psychotic depression and 16 with bipolar psychotic depression - were recruited for the study. The following aspects of validity were investigated: clinical validity, psychometric validity (scalability), and responsiveness.

RESULTS

The PDAS ratings were clinically valid (Spearman's coefficient of correlation between PDAS total scores and Clinical Global Impressions scale - severity of illness ratings=0.66, p<0.001), scalable (Loevinger's coefficient of heterogeneity at endpoint=0.45), and responsive (no participants met the criterion for remission on the PDAS (total score <8) at baseline - at endpoint 74% (95% CI: 60-85) of the participants met this criterion).

CONCLUSIONS

The semi-structured PDAS interview provides valid ratings of the severity of psychotic depression.

A Systematic Review of the Clinimetric Properties of the 6-Item Version of the Hamilton Depression Rating Scale (HAM-D6)

BACKGROUND

In a study aimed at identifying the items carrying information regarding the global severity of depression, the 6-item Hamilton Depression Rating Scale (HAM-D6) was derived from the original 17-item version of the scale (HAM-D17). Since then, the HAM-D6 has been used in a wide range of clinical studies. We now provide a systematic review of the clinimetric properties of HAM-D6 in comparison with those of HAM-D17 and the Montgomery Asberg Depression Rating Scale (MADRS).

METHODS

We conducted a systematic search of the literature in PubMed, PsycInfo, and EMBASE databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Studies reporting data on the clinimetric validity of the HAM-D6 and either the HAM-D17 or MADRS in non-psychotic unipolar or bipolar depression were included in the synthesis.

RESULTS

The search identified 681 unique records, of which 51 articles met the inclusion criteria. According to the published literature, HAM-D6 has proven to be superior to both HAM-D17 and MADRS in terms of scalability (each item contains unique information regarding syndrome severity), transferability (scalability is constant over time and irrespective of sex, age, and depressive subtypes), and responsiveness (sensitivity to change in severity during treatment).

CONCLUSIONS

According to the published literature, the clinimetric properties of HAM-D6 are superior to those of both the HAM-D17 and MADRS. Since the validity of HAM-D6 has been demonstrated in both research and clinical practice, using the scale more consistently would facilitate translation of results from one setting to the other.

Psychotic major depression: challenges in clinical practice and research

Psychotic major depression is an under-researched and under-identified disorder. We highlight the major challenges both in clinical practice and in conducting research with people with this disorder. We also suggest which major issues need addressing to move treatment and knowledge of this disorder forward. Declaration of interest M.H. and A.H.Y. both report grants from the National Institute for Health Research (NIHR).

Peripheral blood microRNA and VEGFA mRNA changes following electroconvulsive therapy: implications for psychotic depression

OBJECTIVE

MicroRNAs are short, non-coding molecules that regulate gene expression. Here, we investigate the role of microRNAs in depression and electroconvulsive therapy (ECT).

METHODS

We performed three studies: a deep sequencing discovery-phase study of miRNA changes in whole blood following ECT (n = 16), followed by a validation study in a separate cohort of patients pre-/post-ECT (n = 37) and matched healthy controls (n = 34). Changes in an experimentally validated gene target (VEGFA) were then analysed in patients pre-/post-ECT (n = 97) and in matched healthy controls (n = 53).

RESULTS

In the discovery-phase study, we found no statistically significant differences in miRNA expression from baseline to end of treatment in the group as a whole, but post hoc analysis indicated a difference in patients with psychotic depression (n = 3). In a follow-up validation study, patients with psychotic depression (n = 7) had elevated baseline levels of miR-126-3p (t = 3.015, P = 0.006) and miR-106a-5p (t = 2.598, P = 0.025) compared to healthy controls. Following ECT, these differences disappeared. Baseline VEGFA levels were significantly higher in depressed patients compared to healthy controls (F(1,144) = 27.688, P = <0.001). Following ECT, there was a significant change in VEGFA levels in the psychotic group only (t = 2.915, P = 0.010).

CONCLUSION

Molecular differences (miRNA and VEGFA) may exist between psychotic and non-psychotic depression treated with ECT.

Clinical Validation of the Psychotic Depression Assessment Scale, Hamilton Depression Rating Scale-6, and Brief Psychiatric Rating Scale-5: Results from the Clinical Research Center for Depression Study

OBJECTIVE

The aim of this study was to validate the psychotic depression assessment scale (PDAS), which includes the six-item melancholia subscale from the Hamilton depression rating scale (HAMD-6) and the five-item psychosis subscale from the brief psychiatric rating scale (BPRS-5). Data from the Clinical Research Center for Depression (CRESCEND) study, which is a 52-week naturalistic trial, were analyzed.

METHODS

Fifty-two patients with psychotic depression from the CRESCEND study met our inclusion criteria. The patients underwent the following psychometric assessments: the PDAS, including HAMD-6 and BPRS-5, the clinical global impression scales, the HAMD, the positive symptom subscale, and the negative symptom subscale. Assessments were performed at the baseline and then at weeks 1, 2, 4, 8, 12, 24, and 52. Spearman correlation analyses were used to assess the clinical validity and responsiveness of the PDAS.

RESULTS

The clinical validity and responsiveness of the PDAS, including HAMD-6 and BPRS-5, were acceptable, with the exception of the clinical responsiveness of the PDAS for positive symptoms and the clinical responsiveness of BPRS-5 for negative symptoms.

CONCLUSION

The clinical relevance of the PDAS has been confirmed and this clinical validation will enhance its clinical utility and availability.

Vigour in active avoidance

It would be maladaptive to learn about catastrophes by trial and error alone. Investment in planning and effort are necessary. Devoting too many resources to averting disaster, however, can impair quality of life, as in anxiety and paranoia. Here, we developed a novel task to explore how people adjust effort expenditure (vigor) so as to avoid negative consequences. Our novel paradigm is immersive, enabling us to measure vigor in the context of (simulated) disaster. We found that participants (N = 118) exerted effort to avoid disaster-associated states, adjusting their effort expenditure according to the baseline probability of catastrophe, in agreement with theoretical predictions. Furthermore, negative subjective emotional states were associated both with threat level and with increasing vigor in the face of disaster. We describe for the first time effort expenditure in the context of irreversible losses, with important implications for disorders marked by excessive avoidance.

Speed of recovery from disorientation may predict the treatment outcome of electroconvulsive therapy (ECT) in elderly patients with major depression

BACKGROUND

No study has previously investigated whether the speed of recovery from disorientation in the post-ictal period may predict the short-term treatment outcome of electroconvulsive therapy (ECT).

METHODS

This longitudinal cohort study included 57 elderly patients with unipolar or bipolar major depression, aged 60-85 years, treated with formula-based ECT. Treatment outcome was assessed weekly during the ECT course using the 17-item Hamilton Rating Scale for Depression (HRSD17). The post-ictal reorientation time (PRT) was assessed at the first and third treatments.

RESULTS

Longer PRTs at the first and third treatments predicted a more rapid decline and a lower end-point in continuous HRSD17 scores (p=0.002 and 0.019, respectively). None of the patients who recovered from disorientation in less than 5 min met the remission criterion, defined as an HRSD17 score of 7 or less. A greater increment in stimulus dosage from the first to the third ECT session rendered a smaller relative decline in PRT (p<0.001).

LIMITATIONS

The limited number of subjects may reduce the generalizability of the findings.

CONCLUSIONS

The speed of recovery from disorientation at the first and third sessions seems to be a predictor of the treatment outcome of formula-based ECT, at least in elderly patients with major depression. It remains to be clarified how the PRT may be utilized to guide stimulus dosing.

Fewer study participants needed to demonstrate superior antidepressant efficacy when using the Hamilton melancholia subscale (HAM-D₆) as outcome measure

BACKGROUND

In the development of new antidepressant treatments, the failed study has unfortunately become a prevalent problem. The number of failed studies could probably be reduced significantly by applying more informative outcome measures. Previous studies have indicated that the 6-item melancholia subscale (HAM-D6) of the 17-item Hamilton Depression Rating Scale (HAM-D17) may be more informative than other scales, due to its superior psychometric properties. In the present study we investigated whether the HAM-D6 had higher informativeness than the HAM-D17 based on data from a randomized placebo-controlled trial (RCT) testing the effect of erythropoietin (EPO) as augmentation therapy in patients with treatment-resistant depression.

METHODS

We assessed the scalability (Mokken analysis of unidimensionality), responsiveness (item responsiveness analysis) and ability to show drug-placebo separation (estimation of sample size needed to detect statistically significant difference between EPO and placebo) of the HAM-D6 and the HAM-D17.

RESULTS

The HAM-D6 demonstrated higher scalability, higher responsiveness, and better drug-placebo separation compared to the HAM-D17. As a consequence, only 39 participants per group would be required to detect a statistically significant difference between EPO and placebo when using the HAM-D6 as outcome measure, whereas the required group size for HAM-D17 would be 146 participants.

LIMITATIONS

The EPO RCT was not originally designed to investigate the research questions addressed in this study.

CONCLUSIONS

Both for ethical and financial reasons it is of interest to minimize the number of participants in clinical trials. Therefore, we suggest employing the HAM-D6 as outcome measure in clinical trials of depression.

Establishing the cut-off score for remission and severity-ranges on the Psychotic Depression Assessment Scale (PDAS)

BACKGROUND

The Psychotic Depression Assessment Scale (PDAS) is a rating scale dedicated to the measurement of severity in psychotic depression (PD). The aim of this study was to establish the PDAS cut-off for remission of PD as well as PDAS score-ranges for mild, moderate, and severe PD. The secondary aim was to test how remission, as defined by the PDAS, would perform as outcome measure when applied to the data from a large randomized controlled trial (RCT) in PD.

METHODS

The study was based on data from the Study of Pharmacotherapy in Psychotic Depression (STOP-PD). The cut-off for remission on the PDAS and the severity-ranges for mild, moderate, and severe PD were defined using the Clinical Global Impression - Severity scale (CGI-S) as reference by means of pair-wise receiver operating characteristic (ROC) analyses. Subsequently, it was tested whether remission on the PDAS could separate the effects of Olanzapine+Sertraline vs. Olanzapine+Placebo through an intention-to-treat, mixed-effects logistic regression of the data from STOP-PD.

RESULTS

According to the ROC analyses, the ideal cut-off for remission of PD was a PDAS total score <8, while the severity-ranges for mild, moderate and severe PD were 8-15, 16-23, and >23 respectively. When applying the PDAS total score <8 (remission) as outcome on the STOP-PD data, treatment with Olanzapine+Sertraline performed significantly better than Olanzapine+Placebo (p<0.001).

LIMITATIONS

The STOP-PD was not designed specifically to answer the research questions of the present study.

CONCLUSIONS

According to this study, a total score <8 on the PDAS corresponds to remission of PD.

Gender Differences in the Clinical Characteristics of Psychotic Depression: Results from the CRESCEND Study

OBJECTIVE

To test whether there are gender differences in the clinical characteristics of patients with psychotic depression (PD).

METHODS

Using data from the Clinical Research Center for Depression (CRESCEND) study in South Korea, we tested for potential gender differences in clinical characteristics among 53 patients with PD. The Psychotic Depression Assessment Scale (PDAS) and other psychometric scales were used to evaluate various clinical features of the study subjects. Independent t-tests were performed for normally distributed variables, Mann-Whitney U-tests for non-normally distributed variables, and χ(2)tests for discrete variables. In addition, to exclude the effects of confounding variables, we carried out an analysis of covariance (ANCOVA) for the normally distributed variables and binary logistic regression analyses for discrete variables, after adjusting the effects of marital status.

RESULTS

We identified more prevalent suicidal ideation (adjusted odds ratio [aOR]=10.316, p=0.036) and hallucinatory behavior (aOR=8.332, p=0.016), as well as more severe anxiety symptoms (degrees of freedom [df]=1, F=6.123, p=0.017), and poorer social and occupational functioning (df=1, F=6.265, p=0.016) in the male patients compared to the female patients.

CONCLUSION

Our findings suggest that in South Korean patients with PD, suicidal ideation, hallucinatory behavior, and anxiety is more pronounced among males than females. This should be taken into consideration in clinical practice.

Rating scales measuring the severity of psychotic depression

OBJECTIVE

Unipolar psychotic depression (PD) is a severe and debilitating syndrome, which requires intensive monitoring. The objective of this study was to provide an overview of the rating scales used to assess illness severity in PD.

METHOD

Selective review of publications reporting results on non-self-rated, symptom-based rating scales utilized to measure symptom severity in PD. The clinical and psychometric validity of the identified rating scales was reviewed.

RESULTS

A total of 14 rating scales meeting the predefined criteria were included in the review. These scales grouped into the following categories: (i) rating scales predominantly covering depressive symptoms, (ii) rating scales predominantly covering psychotic symptoms, (iii) rating scales covering delusions, and (iv) rating scales covering PD. For the vast majority of the scales, the clinical and psychometric validity had not been tested empirically. The only exception from this general tendency was the 11-item Psychotic Depression Assessment Scale (PDAS), which was developed specifically to assess the severity of PD.

CONCLUSION

In PD, the PDAS represents the only empirically derived rating scale for the measurement of overall severity of illness. The PDAS should be considered in future studies of PD and in clinical practice.

Baseline cognitive function does not predict the treatment outcome of electroconvulsive therapy (ECT) in late-life depression

BACKGROUND

No prior study has investigated whether impairment of specific cognitive functions at baseline may predict the short-term treatment outcome of electroconvulsive therapy (ECT) in elderly non-demented patients with major depression (MD).

METHODS

This longitudinal cohort study included 65 elderly patients with unipolar or bipolar MD, aged 60-85 years, treated with formula-based ECT. Treatment outcome was assessed using the 17-item Hamilton Rating Scale for Depression (HRSD17). Cognitive function at baseline was assessed using nine neuropsychological tests or subtests measuring information processing speed, verbal learning and memory, and aspects of executive function.

RESULTS

A poorer performance on the word reading task of the Color Word Interference Test rendered higher odds of achieving remission during the ECT course (p=0.021). Remission was defined as an HRSD17 score of 7 or less. There were no other significant associations between the treatment outcome of ECT and cognitive performance parameters assessed at baseline.

LIMITATIONS

The limited number of subjects may have reduced the generalizability of the findings. Multiple statistical tests increase the risk for making a type I error.

CONCLUSIONS

How well patients perform on neuropsychological tests at baseline is most likely not a predictor of, or otherwise not significantly associated with the treatment outcome of formula-based ECT in elderly patients with MD.

Is the BPRS-5 subscale of the psychotic depression assessment scale a reliable screening tool for psychotic depression?: Results from the CRESCEND study

BACKGROUND

The detection of psychotic depression (PD) among patients with depressive disorders is important for both treatment and monitoring. Therefore, in continuation of our previous work, this study aimed to test the ability of the five-item Brief Psychiatric Rating Scale (BPRS-5) of the Psychotic Depression Assessment Scale (PDAS) in separating patients with psychotic depression from those with non-psychotic depression (non-PD) and to compare this discriminative validity to that of other item sets.

METHODS

A receiver operating characteristics curve was used to identify the optimal cut-off score of the BPRS-5 subscale for sensitive and specific distinction between PD and non-PD in a sample of 494 patients with depressive disorders (53 with PD and 441 with non-PD).

RESULTS

Using an optimal cut-off score of 1, the sensitivity and the specificity of the BPRS-5 subscale in detecting PD were 71.2% and 87.2%, respectively. The BPRS-5 outperformed other item sets of the PDAS and the positive symptom subscale of the BPRS in identifying patients with PD.

LIMITATIONS

The inter-rater reliability of the PDAS and the BPRS-5 subscale was not evaluated in this study.

CONCLUSIONS

The BPRS-5 subscale can be regarded as a more sensitive screening method for PD compared to other item sets from the PDAS and the BPRS. Hence, from a screening perspective, a positive score on any of the five symptoms of the BPRS-5 subscale (hallucinatory behavior, unusual thought content, suspiciousness, blunted affect, and emotional withdrawal) is indicative of PD, and should lead to more thorough diagnostic assessment.

Cognitive markers of psychotic unipolar depression: a meta-analytic study

BACKGROUND

The goal of the current meta-analysis was to review and examine in detail the features of cognitive performance in psychotic (MDDP) versus non-psychotic (MDD) major depressive disorder.

METHODS

An electronic literature search was performed to find studies comparing cognitive performance in MDDP versus MDD. A meta-analysis of broad cognitive domains (processing speed, reasoning/problem solving, verbal learning, visual learning, attention/working memory) and individual cognitive tasks was conducted on all included studies (n=12). Demographic and clinical features were investigated via meta-regression analysis as moderators of cognitive performance.

RESULTS

No difference in socio-demographic and clinical variables was detected between groups. In general, a poorer cognitive performance was detected in MDDP versus MDD subjects (ES=0.38), with a greater effect size in drug-free patients (ES=0.69). MDDP patients were more impaired in verbal learning (ES=0.67), visual learning (ES=0.62) and processing speed (ES=0.71) tasks. A significantly poorer performance was also detected in MDDP patients for individual tasks as Trail Making Test A, WAIS-R digit span backward and WAIS-R digit symbol. Age resulted to have a negative effect on tasks involved in working memory performance.

CONCLUSION

In line with previous meta-analyses, our findings seem to support an association between psychosis and cognitive deficits in the context of affective disorders. Psychosis during the course of MDD is associated with poorer cognitive performance in some specific cognitive domains, such as visual and verbal learning and executive functions.

Clinical and psychometric validation of the psychotic depression assessment scale

BACKGROUND

Recent studies have indicated that the 11-item Psychotic Depression Assessment Scale (PDAS), consisting of the 6-item melancholia subscale (HAM-D6) of the Hamilton Depression Rating Scale and 5 psychosis items from the Brief Psychiatric Rating Scale (BPRS), is a valid measure for the severity of psychotic depression. The aim of this study was to subject the PDAS, and its depression (HAM-D6) and psychosis (BPRS5) subscales to further validation.

METHODS

Patients diagnosed with psychotic depression at Danish psychiatric hospitals participated in semi-structured interviews. Video recordings of these interviews were assessed by two experienced psychiatrists (global severity rating of psychotic depression, depressive symptoms and psychotic symptoms) and by two young physicians (rating on 27 symptom items, including the 11 PDAS items). The clinical validity and responsiveness of the PDAS and its subscales was investigated by Spearman correlation analysis of the global severity ratings and the PDAS, HAM-D6, and BPRS5 total scores. The unidimensionality of the scales was tested by item response theory analysis (Mokken).

RESULTS

Ratings from 39 participants with unipolar psychotic depression and nine participants with bipolar psychotic depression were included in the analysis. The Spearman correlation analysis indicated that the PDAS, HAM-D6 and BPRS5 were clinically valid (correlation coefficients from 0.78 to 0.85, p<0.001) and responsive (correlation coefficients from 0.72 to 0.86, p<0.001) measures of psychotic depression. According to the Mokken analysis, all three scales were unidimensional.

CONCLUSIONS

The clinical validity, responsiveness and unidimensionality of the PDAS and its subscales were confirmed in an independent sample of patients with psychotic depression.

Is the Psychotic Depression Assessment Scale a useful diagnostic tool? The CRESCEND study

BACKGROUND

The Psychotic Depression Assessment Scale (PDAS) has been validated as a method of assessing the severity and treatment outcomes of psychotic depression (PD). We aimed to compare the results of the PDAS in PD and non-psychotic depression (non-PD) patients and validate the PDAS as a diagnostic tool for PD.

METHODS

We included 53 patients with PD and 441 with non-PD who participated in the Clinical Research Center for Depression study in South Korea. In addition to the PDAS, psychometric tools including the HAMD17, HAMA, BPRS, CGI-S, SOFAS, SSI-Beck, WHOQOL-BREF, AUDIT, and FTND were used to assess, respectively, depression, anxiety, overall symptoms, global severity, social functioning, suicidal ideation, quality of life, alcohol use, and nicotine use.

RESULTS

After adjusting for age and total HAMD17 score, PD patients had higher scores for depressive mood, hallucinations, unusual thought content, suspiciousness, blunted affect, and emotional withdrawal on the PDAS and higher total scores on the SSI-Beck than non-PD patients. Binary logistic regression identified hallucinatory behavior and emotional withdrawal as predictors of PD. Receiver operating characteristic analysis showed that emotional withdrawal could be used to differentiate psychotic from non-psychotic depression.

LIMITATIONS

The inter-rater reliability for psychometric assessments was not evaluated.

CONCLUSIONS

In addition to assessing the severity and treatment outcomes of PD, PDAS can help in the diagnosis of PD.

Brief, unidimensional melancholia rating scales are highly sensitive to the effect of citalopram and may have biological validity: implications for the research domain criteria (RDoC)

BACKGROUND

Most depression rating scales are multidimensional and the resulting heterogeneity may impede identification of coherent biomarkers. The aim of this study was to compare the psychometric performance of the multidimensional 17-item Hamilton Depression Rating Scale (HAM-D17) and the 30-item Inventory of Depressive Symptomatology (IDS-C30) to that of their unidimensional six-item melancholia subscales (HAM-D6 and IDS-C6).

METHODS

A total of 2242 subjects from level 1 (citalopram) of the Sequenced Treatment Alternatives to Relieve Depression (STAR* study were included in the analysis. Symptom change, response and remission rates were compared for HAM-D6 versus HAM-D17 and for IDS-C6 versus IDS-C30. The changes in total scores on these scales were compared to the change in Quality of Life Enjoyment and Satisfaction Questionnaire (QLES-Q) score using correlation analysis.

RESULTS

The response to treatment was significantly greater according to the HAM-D6 and IDS-C6. Furthermore, the correlation of changes in depression-ratings with changes in QLES-Q scores were comparable for the subscales and full scales.

LIMITATIONS

STAR*D was not designed to answer the research questions addressed in this analysis.

CONCLUSIONS

Our findings indicate that the HAM-D6 and IDS-C6 melancholia scales capture a coherent construct in depression. The syndrome reflected in these scales is unidimensional, sensitive to specific pharmacological intervention, and therefore likely to have biological validity. We therefore believe that "melancholia" thus defined could be a valuable construct under the Research Domain Criteria (RDoC), which specifically aims at identifying the neurobiology underlying mental disorders and providing drugable targets.

Measuring treatment response in psychotic depression: the Psychotic Depression Assessment Scale (PDAS) takes both depressive and psychotic symptoms into account

BACKGROUND

There is no established psychometric instrument dedicated to the measurement of severity in psychotic depression (PD). The aim of this study was to investigate whether a new composite rating scale, the Psychotic Depression Assessment Scale (PDAS), covering both the psychotic and the depressive domains of PD, could detect differences in effect between two psychopharmacological treatment regimens.

METHODS

We reanalyzed the data from the Study of Pharmacotherapy of Psychotic Depression (STOP-PD), which compared the effect of Olanzapine+Sertraline (n=129) versus Olanzapine+Placebo (n=130). The response to the two regimens was compared using both a mixed effects model and effect size statistics on the total scores of three rating scales: the 17-item Hamilton Depression Rating Scale (HAM-D17), its 6-item melancholia subscale (HAM-D6), and the 11-item PDAS consisting of the HAM-D6 plus five items from the Brief Psychiatric Rating Scale covering psychotic symptoms.

RESULTS

According to both statistical approaches, the PDAS, the HAM-D17 and the HAM-D6 were all able to detect significant differences in treatment effect between Olanzapine+Sertraline and Olanzapine+Placebo (Olanzapine+Sertraline being superior). Notably, 45% of the trial participants were at least "probable psychotic" at their last assessment in the trial.

LIMITATIONS

The STOP-PD was not designed specifically to answer the research questions of the present study.

CONCLUSIONS

The Psychotic Depression Assessment Scale (PDAS) is a sensitive measure of treatment response in PD. The fact that 45% of the patients still experienced psychotic symptoms at their last trial assessment emphasizes the need to include items pertaining to psychotic symptoms in rating scales for PD.