Randomized clinical trials underestimate the efficacy of antidepressants in less severe depression

Anorexia Nervosa With Comorbid Severe Depression: A Systematic Scoping Review of Brain Stimulation Treatments

ABSTRACT

Major depressive disorder (MDD) is highly prevalent in individuals with anorexia nervosa (AN) and is a predictor of greater clinical severity. However, there is a limited amount of evidence supporting the use of psychotropic medications for its management. A systematic scoping review was conducted to assess the current literature on brain stimulation treatments for AN with comorbid MDD, with a specific focus on MDD treatment response and weight restoration. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the PubMed, PsycInfo, and MEDLINE databases were searched until July 2022 using specific key words related to AN and brain stimulation treatments. A total of 373 citations were identified, and 49 treatment studies that met the inclusion criteria were included in the review. The initial evidence suggests that electroconvulsive therapy, repetitive transcranial magnetic stimulation, and deep-brain stimulation may be effective in managing comorbid MDD in AN. Emerging evidence suggests that transcranial direct current stimulation may have a positive effect on body mass index in individuals with severe to extreme AN. However, there is a need for the development of better measurement techniques for assessing the severity of depression in the context of AN. Controlled trials that are adequately designed to account for these limitations are highly warranted for deep-brain stimulation, electroconvulsive therapy, and repetitive transcranial magnetic stimulation and hold promise for providing clinically meaningful results.

Initial severity of the Positive and Negative Syndrome Scale (PANSS)-30, its main subscales plus the PANSS-6, and the relationship to subsequent improvement and trial dropout: a pooled participant-level analysis of 18 placebo-controlled risperidone and paliperidone trials

Greater initial severity on the 30-item Positive and Negative Syndrome Scale (PANSS-30) correlates positively with antipsychotic-placebo separation and trial dropout, but it is unknown whether these associations are present also on PANSS-derived subscales. We assessed the relationship between initial severity and antipsychotic-placebo separation as measured by PANSS-30 and four PANSS symptom subscales: the positive (PANSS-POS), negative (PANSS-NEG), general (PANSS-GEN) and 6-item (PANSS-6) subscales, using patient-level data from 18 placebo-controlled risperidone and paliperidone trials. Analysis of covariance in the intention-to-treat population (last-observation-carried-forward) was used to assess antipsychotic-placebo separation and trial dropout. Across 6685 participants (90% schizophrenia, 10% schizoaffective disorder), the initial severity-by-treatment interaction was statistically significant for PANSS-30 (beta: -0.155; p < 0.001) and all PANSS subscales (beta range: -0.097 to -0.135; p-value range: < 0.001 to 0.002). In all cases, antipsychotic-placebo differences increased with initial severity. Judging by the distribution of relative outcomes (percent remaining symptoms), the interaction was partly explained by an increased chance of responding, but also by larger numerical responses in those who did respond, as initial severity increased. Except for PANSS-NEG, high initial severity on all PANSS scales predicted increased trial dropout, although not statistically significantly so for PANSS-6. In summary, we thus replicate previous findings showing greater initial severity to predict larger antipsychotic-placebo separation and extend these results to four PANSS subscales. For PANSS-POS and PANSS-GEN, but not for PANSS-NEG and PANSS-6, we also replicate the association between initial severity and trial dropout. Patients with low initial negative symptom severity were identified as a group of particular interest for further study since their results diverged most from the average both with regard to antipsychotic-placebo separation (low separation measured by PANSS-NEG) and trial dropout (high level).

Health-related quality of life-based definition of remission from depression among primary care patients

Background

Depression undermines health-related quality of life (HRQoL). Remission is the central aim of all treatments for depression, but the degree of remission necessary for depressive patients' HRQoL to correspond to the normal range of the general population remains unknown.

Methods

The Vantaa Primary Care Depression Study prospectively followed-up a screening-based cohort of depressive primary care patients for 5 years. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was used to diagnose major depressive disorder. HRQoL was measured by the generic 15D instrument at baseline and at 5 years (N = 106, 77% of baseline patients), and compared with the 15D results of an age-standardized general population sample from the Finnish Health 2011 Survey (N = 4,157). Receiver operating characteristic analyses determined the optimal Hamilton Depression Rating Scale (HAMD), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) cut-offs for remission, using the 15D score as the construct validator. Remission was defined as the score at which HRQoL reached the general population range (minimum mean - 1 SD). As age may influence HRQoL, patients older and younger than the median 52 years were investigated separately.

Results

For HAMD, the optimal cut-off point score was 8.5, for BDI 10.5, and for BAI 11.5. The differences between the findings of the younger and older patients were small.

Limitations

Cross-sectional analysis, small number of patients in the cohort.

Conclusion

Depressive primary care patients' HRQoL reaches the normal variation range of the general population when their depression and anxiety scores reach the conventional clinical cut-offs for remission.

Perspectives on the success rate of current antidepressant pharmacotherapy

INTRODUCTION

There has been growing debate about the effectiveness of traditional antidepressants for the treatment of depression, and whether the clinical trials literature overstates the value of existing agents. Antidepressant efficacy is limited by suboptimal remission rates, lack of robust efficacy across diverse depressed subgroups, slow onset, and challenges managing tolerability. Clinicians can better navigate uncertainties in this area by recognizing patient-specific clinical and prognostic factors that influence the likelihood of antidepressant drug response.

AREAS COVERED

The author summarizes pertinent literature regarding drug-placebo differences in antidepressant outcome as well as patient-specific factors that influence antidepressant drug responsivity across subtypes of depressive disorders.

EXPERT OPINION

Standardized effect sizes for most monoaminergic antidepressants are relatively modest. At least one-third of treatment response derives from nonspecific (yet substantial) placebo effects, limiting the ability to compare antidepressant medication effects to that of "no treatment." Patients with high baseline depressive symptom severity are less likely to respond to placebo but may be more responsive to antidepressant pharmacotherapy than is the case in mild forms of depression. Patient satisfaction with antidepressant response must take into consideration not only efficacy for reducing symptoms but also drug tolerability/acceptability and tangible improvement in functional outcome and quality of life.

Antidepressant efficacy of Agomelatine: Meta-analysis of placebo controlled and active comparator studies

Agomelatine is a novel antidepressant that was developed to counter the adverse effects associated with the standard SSRIs and SNRIs that limited their usage. Publication bias was identified in antidepressant trials which can potentially overestimate the treatment efficacy. This meta-analysis was designed to assess the overall antidepressant effect of Agomelatine by pooling all the published and unpublished studies available till date. Studies conducted on adult patients who met with the criteria for MDD that evaluated efficacy of Agomelatine at acute phase (6-12weeks) and at long term phase (24weeks) were included. The primary efficacy measured with SMD of final mean scores of HAM-D and MADRS. Secondary efficacy measures of Response, remission and safety parameters were evaluated with relative risks. RevMan version 5.4 was used for analysis of both continuous (Standardized mean difference) and dichotomous outcomes (response, remission and all cause of discontinuation). Efficacy parameters were presented with 99% confidence intervals while safety parameters were presented with 95% CI. A total of 9233 patients were included from 27 studies. In acute phase placebo controlled studies, Agomelatine had a statistically significant SMD of - 0.24 (-0.39 to -0.09) and response rate of (1.25, 1.07-1.47). In comparison (RR 0.99, 0.92-1.07) Agomelatine is an effective antidepressant having similar efficacy with the currently used antidepressants.

The Effects of Exclusively Resistance Training-Based Supervised Programs in People with Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The purpose of this study was to systematically review the effects of supervised resistance training (RT) programs in people diagnosed with depression or depressive symptoms. The following databases were used to search and retrieve the articles: Cochrane Library, EBSCO, PEDro, PubMed, Scopus and Web of Science. The search was conducted in late June 2020. Search protocol required the title to contain the words depression or depressive or dysthymia. Furthermore, the title, abstract or keywords had to contain the words or expressions: "randomized controlled trial"; and "strength training" or "resistance training" or "resisted training" or "weight training". The screening provided 136 results. After the removal of duplicates, 70 records remained. Further screening of titles and abstracts resulted in the elimination of 57 papers. Therefore, 13 records were eligible for further scrutiny. Of the 13 records, nine were excluded, and the final sample consisted of four articles. Results were highly heterogeneous, with half of the studies showing positive effects of resistance training and half showing no effects. In two of the four combinations, the meta-analysis revealed significant benefits of RT in improving depressive symptoms (p ≤ 0.05). However, considering significant differences with moderate (Effect Size = 0.62) and small (ES = 0.53) effects, the heterogeneity was above 50%, thus suggesting a substantial level. To draw meaningful conclusions, future well-designed randomized controlled trials (RCTs) are needed that focus on understudied RT as a treatment for depression.

Influence of baseline severity on the effects of SSRIs in depression: an item-based, patient-level post-hoc analysis

BACKGROUND

Reports claiming that antidepressants are effective only in patients with severe depression have affected treatment guidelines but these reports usually use a disputed measure of improvement, a decrease in the sum-score of the 17-item Hamilton Depression Rating Scale (HDRS-17), and are based on group-level rather than patient-level data.

METHOD

In this item-based, patient-level, post-hoc analysis, we pooled data from all completed, acute-phase, placebo-controlled, industry-sponsored, HDRS-based trials of the SSRIs citalopram, paroxetine, or sertraline in adult major depression. Patient-level data were pooled and subjected to item-based post-hoc analyses to assess the effect of baseline severity of depression on the response to treatment as assessed with HDRS-17 sum score, the depressed mood item of the HDRS, a six-item HDRS subscale (HDRS-6), and the remaining 11 HDRS items not included in this subscale (non-HDRS-6). Patients were defined as having non-severe depression if they had a baseline HDRS-17 sum score of 18 points or less and as having severe depression if they had a score of 27 points or more.

FINDINGS

Our study population consisted of 8262 patients from 28 placebo-controlled SSRI trials. Participants were treated with either citalopram (n=744), paroxetine (n=2981), sertraline (n=1202), fluoxetine (active-control group; n=754), or placebo (n=2581). 654 patients were defined as having non-severe depression and 1377 as having severe depression. Patients with non-severe and severe depression did not differ with respect to SSRI-induced decrease in depressed mood and other HDRS symptoms belonging to the HDRS-6 subscale. However, after exclusion of patients with rare extreme baseline values, a positive association was seen between severity and efficacy when using HDRS-17 sum score as the effect parameter. This result was largely due to a more pronounced response to treatment with respect to non-HDRS-6 items in patients with severe depression than in those with non-severe depression. This outcome could be explained by non-HDRS-6 items, more so than HDRS-6 items, being more severe and prevalent at baseline in severe than in non-severe cases; hence, less room was left for improvement in these areas in patients with non-severe depression.

INTERPRETATION

The use of an outcome measure that includes symptoms that rate low at baseline in patients with non-severe depression might result in the interpretation that SSRIs are ineffective in these patients. With respect to alleviation of HDRS-6 items, SSRIs appear to be as effective in patients with non-severe depression as in those with severe depression.

FUNDING

Swedish Medical Research Council, AFA Insurance, Swedish Brain Foundation, Sahlgrenska University Hospital (Avtal om Läkarutbildning och Forskning), Bertil Hållsten's Foundation, and Söderberg's Foundation.

Efficacy of antidepressants: bias in randomized clinical trials and related issues

INTRODUCTION

Countless antidepressant randomized trials were conducted and showed statistically significant benefits of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) over placebo. Meanwhile, critics are increasing regarding the efficacy of antidepressants in the treatment of MDD because at least a proportion of clinical trials could be hampered by various biases. In contrast, number of failed trials is increasing in the recent years which have made developing psychiatric medications progressively more time-consuming and expensive. Areas covered: Biases and related issues in clinical trials for antidepressants can be identified as an important common contributing factor to the two paradoxical phenomenon. This review identifies possible biases that can occur before, during, and after clinical trials of antidepressant. Expert commentary: Recent studies not only may over-estimate efficacy of antidepressants, but also may exaggerate placebo response because of various biases. Sponsorship and publication biases have been one of the targets of the criticism and ethical debate. Thus, initiating new trend of research by re-organizing academic-industry partnership will be the most important task in the next five years.

Predicting response to treatment and discriminating bipolar and depression symptoms using Hamilton Depression Rating Scale

ABSTRACT Objective The present study aims to compare the diagnostic ability of the HAMD 17 items with shorter versions of 7 and 6 items. Methods A total of 133 patients from a 6 month clinical trial diagnosed with mood disorders (60.2% with Major Depressive Disorder and 39.8% with bipolar type I disorder) were recruited. Results The 17 items HAMD scale showed similar results as compared with shorter versions. Furthermore, almost all patients’ diagnosed with Major Depressive Disorder scored more compared to Bipolar Disorder, but the difference was not significant. Conclusion This study allows that the use of a shorter version of HAMD might be an adequate possibility, and also that depressive symptoms were similar among groups.

Illness severity and biomarkers in depression: Using a unidimensional rating scale to examine BDNF

BACKGROUND

Numerous studies have reported reduced peripheral brain-derived neurotrophic factor (BDNF) in major depression (MD). However, most of these studies used multidimensional depression rating scales, and failed to identify a relationship between BDNF levels and depression severity. Unidimensional scales are a more valid measure of syndrome severity. In these scales, items are ordered in increasing severity, so that as scores increase, syndrome severity increases; thus, each item adds unique information, and items can be totaled to a meaningful sum. The current study used the HAM-D6, a unidimensional measure of depression, to examine if it could identify a correlation between serum BDNF and depression severity.

METHODS

Serum BDNF levels and symptom severity were assessed in 163 depressed patients, including those with both unipolar (84.0%) and bipolar (16.0%) depression. The evaluation of depression severity included the total HAM-D17 and 3 subscales, including the HAM-D6.

RESULTS

On average, patients presented moderate to severe depression (HAM-D17=21.2±5.5). Overall BDNF levels were 60.4±22.6ng/mL. The correlation between serum BDNF and depression severity was modest and not different when assessed by the HAM-D6 subscale or the HAM-D17 as a whole (z=0.951; p=0.341), despite being statistically significant for the HAM-D6 (r=-0.185; p=0.019; 95% CI: -0.335 to -0.033), but not for the entire HAM-D17 (r=-0.127; p=0.108; 95% CI: -0.272 to 0.027).

CONCLUSION

We could not identify a strong relationship between serum BDNF levels and depression severity using the HAM-D6. This is in concordance with results of previous studies that reported no correlation between these variables, and indicates that the properties of the clinical measures used cannot explain the results these studies.

A critical review of exercise as a treatment for clinically depressed adults: time to get pragmatic

OBJECTIVE

Although considerable evidence supports the efficacy of exercise as an antidepressant treatment, critical reviews informing routine practice and future research directions are scarce.

METHODS

We critically reviewed exercise studies for clinically depressed adults, focussing on the PICOS criteria referred to participants, interventions, comparisons, outcomes, and study designs.

RESULTS

Most studies have not screened their samples for symptom heterogeneity. Also, they have employed heterogeneous exercise interventions and control groups that may lead to an underestimation of the benefits of exercise. In addition, pragmatic trials allowing scalable replication and implementation in routine practice are scarce. Future studies, can consider the research domain criteria as a diagnostic framework, and conduct moderator analyses to identify depressed subgroups with symptomatology and biopsychosocial characteristics associated with differential responses to exercise interventions. The search for biomarkers of the antidepressant responses to exercise should be prioritised. Further, non-physically active comparison groups should be used to minimise treatment cross-overs and thus the underestimation of the effects of exercise interventions. Finally, the use of outcome measures that maintain their validity at low and moderate levels of symptom severity and the development of trials with a pragmatic design are essential.

CONCLUSION

The current evidence base is fraught with methodological considerations that need to be taken into account in order to increase further our understanding on the impact of exercise as medicine in depression. Future research should include moderator analyses, incorporate biomarker assays, use appropriate control and comparison groups, assess outcomes with psychometrically sensitive measures, and prioritise pragmatic trials towards transition to routine practice.

Consistent superiority of selective serotonin reuptake inhibitors over placebo in reducing depressed mood in patients with major depression

The recent questioning of the antidepressant effect of selective serotonin reuptake inhibitors (SSRIs) is partly based on the observation that approximately half of company-sponsored trials have failed to reveal a significant difference between active drug and placebo. Most of these have applied the Hamilton depression rating scale to assess symptom severity, the sum score for its 17 items (HDRS-17-sum) serving as effect parameter. In this study, we examined whether the negative outcomes of many SSRI trials may be partly caused by the use of this frequently questioned measure of response. We undertook patient-level post-hoc analyses of 18 industry-sponsored placebo-controlled trials regarding paroxetine, citalopram, sertraline or fluoxetine, and including in total 6669 adults with major depression, the aim being to assess what the outcome would have been if the single item depressed mood (rated 0-4) had been used as a measure of efficacy. In total, 32 drug-placebo comparisons were reassessed. While 18 out of 32 comparisons (56%) failed to separate active drug from placebo at week 6 with respect to reduction in HDRS-17-sum, only 3 out of 32 comparisons (9%) were negative when depressed mood was used as an effect parameter (P<0.001). The observation that 29 out of 32 comparisons detected an antidepressant signal from the tested SSRI suggests the effect of these drugs to be more consistent across trials than previously assumed. Further, the frequent use of the HDRS-17-sum as an effect parameter may have distorted the current view on the usefulness of SSRIs and hampered the development of novel antidepressants.

Efficacy and tolerability of antidepressants for sub-threshold depression and for mild major depressive disorder

BACKGROUND

It is commonly assumed that robust evidence exists for the lack of efficacy of antidepressants at the milder end of the depression severity spectrum. In light of specific limitations of existing reviews, we assess if antidepressants are efficacious and tolerable for sub-threshold or mild major depressive disorder (MDD).

METHOD

Systematic review and meta-analysis of randomised controlled trials of adults with sub-threshold depression or mild MDD (initial baseline symptom severity of HRSD≤20) comparing an antidepressant with placebo or treatment as usual (TAU) however defined. A pre-specified protocol was published (Prospero reference: CRD42013004505).

RESULTS

8 trials were included: 5 trials (453 participants) of sub-threshold depression and 3 trials (502 participants) of mild MDD. Trials of sub-threshold depression exhibited low risk of bias whereas those of mild MDD exhibited high risk. Two trials of sub-threshold depression were pooled (n=102) to assess efficacy and favoured antidepressants over placebo statistically but the difference was small and unlikely to be clinically meaningful: mean difference -1.39 (-2.41, -0.36). Due to heterogeneity, no trials of mild MDD could be pooled for efficacy. There was no difference between antidepressant treatment and placebo for drop out due to adverse events. The maximum proportion in those receiving antidepressants dropping out due to adverse events was 17%, with indication of a dose effect.

LIMITATIONS

Not all data from identified trials could be included in the meta-analyses due to a lack of availability of relevant data.

CONCLUSION

There is insufficient evidence to support or contest the efficacy of antidepressant medication for sub-threshold depression or mild MDD. More trials, with adequate follow up, are required to address this question.

Depression symptom clusters and their predictive value for treatment outcomes: results from an individual patient data meta-analysis of duloxetine trials

We evaluated individual patient data from phase II to IV clinical trials of duloxetine in major depressive disorder (MDD) (34 studies, 13,887 patients). Our goal was to identify clusters of patients with similar depressive symptom patterns at baseline, as measured by the 17-item Hamilton Depression Rating Scale (HAMD-17), and to investigate their respective predictive value of outcomes as measured by the HAMD-17 total score. Five clusters were identified at baseline: 1) "Lack of insight"; 2) "Sleep/sexual/somatic"; 3) "Typical MDD"; 4) "Gastrointestinal/weight loss"; and 5) "Mild MDD". However, it should be noted that cluster descriptors are not mutually exclusive. Analyses of the HAMD-17 total score results over time were performed using the 18 randomized placebo and/or actively controlled studies representing 6723 patients. At the end of acute treatment (ranging from 4 to 36 weeks), different levels of effect sizes for active therapy (64.5% duloxetine) vs. placebo were detected by cluster. In 3 out of 5 clusters (representing about 80% of the patients), the effect size was significantly different from 0, in favor of active therapy. The effect size was largest in those clusters with severe somatic symptoms ("Sleep/sexual/somatic" cluster [-0.4170], and "Gastrointestinal/weight loss" cluster [-0.338]). In conclusion, our cluster analysis identified 5 clinically relevant MDD patient clusters with specific mean treatment outcomes. Identification of MDD clusters may help to improve outcomes by adapting MDD treatment to particular clinical profiles.

A comparison of three methods of assessing differential item functioning (DIF) in the Hospital Anxiety Depression Scale: ordinal logistic regression, Rasch analysis and the Mantel chi-square procedure

PURPOSE

It is important for clinical practice and research that measurement scales of well-being and quality of life exhibit only minimal differential item functioning (DIF). DIF occurs where different groups of people endorse items in a scale to different extents after being matched by the intended scale attribute. We investigate the equivalence or otherwise of common methods of assessing DIF.

METHOD

Three methods of measuring age- and sex-related DIF (ordinal logistic regression, Rasch analysis and Mantel χ(2) procedure) were applied to Hospital Anxiety Depression Scale (HADS) data pertaining to a sample of 1,068 patients consulting primary care practitioners.

RESULTS

Three items were flagged by all three approaches as having either age- or sex-related DIF with a consistent direction of effect; a further three items identified did not meet stricter criteria for important DIF using at least one method. When applying strict criteria for significant DIF, ordinal logistic regression was slightly less sensitive.

CONCLUSIONS

Ordinal logistic regression, Rasch analysis and contingency table methods yielded consistent results when identifying DIF in the HADS depression and HADS anxiety scales. Regardless of methods applied, investigators should use a combination of statistical significance, magnitude of the DIF effect and investigator judgement when interpreting the results.

Antidepressants and the risk of suicide in young persons--prescription trends and toxicological analyses

OBJECTIVE

To assess trends in the use of antidepressants among young suicides after the warning that these drugs might increase the risk of suicide.

METHOD

Individual data of all 845 suicides in the 10- to 19-year age group in Sweden in the time period 1992-2003 (baseline), and in 2004-2010 (after the warning). Outcome data are prescriptions of antidepressants prior to death and detections of antidepressants in post-mortem toxicology.

RESULTS

After the warning, suicide in this age group increased for five consecutive years (60.5%). The increase occurred among individuals not treated with antidepressants.

CONCLUSION

This study provides further support for the hypothesis that the warning, contrary to its intention, may have increased young suicides by leaving a number of suicidal young persons without treatment with antidepressants.

Agomelatine efficacy and acceptability revisited: systematic review and meta-analysis of published and unpublished randomised trials

BACKGROUND

Agomelatine is a novel antidepressant drug with narrative, non-systematic reviews making claims of efficacy.

AIMS

The present study systematically reviewed published and unpublished evidence of the acute and long-term efficacy and acceptability of agomelatine compared with placebo in the treatment of major depression.

METHOD

Randomised controlled trials comparing agomelatine with placebo in the treatment of unipolar major depression were systematically reviewed. Primary outcomes were (a) Hamilton Rating Scale for Depression (HRSD) score at the end of treatment (short-term studies) and (b) number of relapses (long-term studies).

RESULTS

Meta-analyses included 10 acute-phase and 3 relapse prevention studies. Seven of the included studies were unpublished. Acute treatment with agomelatine was associated with a statistically significant superiority over placebo of -1.51 HRSD points (99% CI -2.29 to -0.73, nine studies). Data extracted from three relapse prevention studies failed to show significant effects of agomelatine over placebo (relative risk 0.78, 99% CI 0.41-1.48). Secondary efficacy analyses showed a significant advantage of agomelatine over placebo in terms of response (with no effect for remission). None of the negative trials were published and conflicting results between published and unpublished studies were observed.

CONCLUSIONS

We found evidence suggesting that a clinically important difference between agomelatine and placebo in patients with unipolar major depression is unlikely. There was evidence of substantial publication bias.

Does adding noradrenaline reuptake inhibition to selective serotonin reuptake inhibition improve efficacy in patients with depression? A systematic review of meta-analyses and large randomised pragmatic trials

Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line pharmacological treatment for depression and are the most commonly prescribed class of antidepressants. However, there is substantial evidence that noradrenaline has a role in the pathogenesis and treatment of depression. This review aims to examine the evidence of including noradrenaline reuptake inhibition with serotonin reuptake inhibition with respect to increasing efficacy in the treatment of depression. Evidence from meta-analysis of randomised controlled trials (RCTs) and randomised pragmatic trials was found in support of greater efficacy of the serotonin noradrenaline reuptake inhibitors (SNRIs), venlafaxine and duloxetine, in moderate to severe depression compared to SSRIs but no evidence was found for superiority of milnacipran. There is sufficient current evidence that demonstrates an increase in efficacy, when noradrenaline reuptake is added to serotonin (5-HT) reuptake, to suggest that patients with severe depression or those who have failed to reach remission with a SSRI may benefit from treatment with a SNRI. However, as these conclusions are drawn from the evidence derived from meta-analyses and pragmatic trials, large adequately powered RCTs using optimal dosing regimens and clinically relevant outcome measures in severe depression and SSRI treatment failures are still required to confirm these findings.

Psychometric properties of the Quick Inventory of Depressive Symptomatology (QIDS-SR) in UK primary care

It is widely believed that severity of depressive disorder should guide treatment selection and many guidelines emphasise this factor. The Quick Inventory of Depressive Symptomatology (QID-SR16) is a self-complete measure of depression severity which includes all DSM-IV criterion symptoms for major depressive disorder. The object of this study was to assess the psychometric properties of the QIDS-SR16 in a primary care sample. Adult primary care patients completed the QIDS-SR16 and were assessed by a psychiatrist (blind to QIDS-SR16) with the 17-item Hamilton Rating Scale for Depression (GRID-HAMD). Internal consistency, homogeneity and convergent and discriminant validity of the QIDS-SR16 were assessed. Severity cut-off scores for QIDS-SR16 were assessed for convergence with HRSD-17 cut-offs. Published methods for converting scores to HRSD-17 were also assessed. Two hundred and eighty-six patients participated: mean age = 49.5 (s.d. = 13.8), 68% female, mean HRSD-17 = 12.6 (s.d. = 7.6). The QIDS-SR16 exhibited acceptable internal consistency (Cronbach's alpha = 0.86), a robust factor structure indicating one underlying dimension and correlated highly with the HRSD-17 (r = 0.79) but differed significantly in how it categorised the severity of depression relative to the HRSD-17 (Wilcoxon Signed Rank Test p < 0.001). Using published methods to convert QIDS-SR16 scores to HRSD-17 scores did not result in alignment of severity categorisation. In conclusion, psychometric properties of the QIDS-SR16 were found to be strong in terms of internal consistency, factor structure and convergent and discriminant validity. Using conventional scoring and conversion methods the scale was found not to concur with the HRSD-17 in categorising the severity of depressive symptoms.

Differential item functioning of the HADS and PHQ-9: an investigation of age, gender and educational background in a clinical UK primary care sample

BACKGROUND

The Patient Health Questionnaire (PHQ-9) and Hospital Anxiety and Depression Scale (HADS) are commonly used measures in clinical practice and research. It is important that such scales measure the trait they purport to measure and that the impact of other measurement artefacts is minimal. Differential item functioning of these scales by gender, educational background and age is currently assessed.

METHODS

Severity of depression and anxiety symptoms were measured in primary care patients referred to mental health workers using the PHQ-9 and HADS. Each scale was assessed for Differential Item Functioning (DIF) and Differential Test Function (DTF) by gender, educational background and age. Minimum n per analysis=895. DIF was assessed with Mantel's χ(2), Liu-Agresti cumulative common odds ratio (LA LOR) and the standardised LA LOR (LA LOR-Z). DTF was assessed in relation to ν(2).

RESULTS

PHQ-9, HADS Depression Sub-scale (HADS-D) and HADS Anxiety Subscale (HADS-A) lacked bias in terms of gender and educational background (ν(2)<0.07). However, both PHQ-9 and HADS-D exhibited bias with regard to age: PHQ-9 ν(2)=0.103 (medium effect); HADS-D ν(2)=0.214 (large effect). PHQ-9 items exhibiting DIF by age covered: anhedonia, energy and low mood. HADS-D items exhibiting DIF by age covered psychomotor retardation and interest in appearance.

LIMITATIONS

No assessment of other potential DIF contributors was made.

CONCLUSIONS

PHQ-9, HADS-D and HADS-A generally do not exhibit bias for gender and educational background. However bias was observed in PHQ-9 and HADS-D for age. Caution should be exercised interpreting scores both in clinical practice and research.

Primary care physicians' and psychiatrists' approaches to treating mild depression

OBJECTIVE

To measure how primary care physicians (PCPs) and psychiatrists treat mild depression.

METHOD

We surveyed a national sample of US PCPs and psychiatrists using a vignette of a 52-year-old man with depressive symptoms not meeting Major Depressive Episode criteria. Physicians were asked how likely they were to recommend an antidepressant counseling, combined medication, and counseling or to make a psychiatric referral.

RESULTS

Response rate was 896/1427 PCPs and 312/487 for psychiatrists. Compared with PCPs, psychiatrists were more likely to recommend an antidepressant (70% vs. 56%), counseling (86% vs. 54%), or the combination of medication and counseling (61% vs. 30%). More psychiatrists (44%) than PCPs (15%) were 'very likely' to promote psychiatric referral. PCPs who frequently attended religious services were less likely (than infrequent attenders) to refer the patient to a psychiatrist (12% vs. 18%); and more likely to recommend increased involvement in meaningful relationships/activities (50% vs. 41%) and religious community (33% vs. 17%).

CONCLUSION

Psychiatrists treat mild depression more aggressively than PCPs. Both are inclined to use antidepressants for patients with mild depression.

Psychiatry should not become hostage to placebo: an alternative interpretation of antidepressant-placebo differences in the treatment response in depression

BACKGROUND

It is widely believed that in randomized controlled trials of antidepressants the difference between drug and placebo response rates is rather small (around 20%), leading to a common perception that antidepressants have limited efficacy.

AIM

The aim of the present paper was to present an alternative calculation and interpretation of antidepressant-placebo difference in the treatment response to antidepressant in drug trials which may shed a new light on the efficacy of antidepressants.

ISSUES

We have previously highlighted several controversial points concerning the calculation of antidepressant and placebo response rates in randomised controlled trials, which may influence views concerning the efficacy of drugs, and demonstrated several factors which may lead to overestimation of the placebo effect and underestimation of antidepressant efficacy. The traditional interpretation of antidepressant-placebo difference in randomized controlled trials on major depression has been also challenged previously from at least five points of view but all leading to a conclusion that currently prevailing opinions concerning relative placebo and antidepressant response rates overestimate placebo response, and thereby underestimate efficacy of antidepressant drugs. In our present paper we propose another method for calculating placebo and antidepressant response rates which may shed new light on an overlooked aspect of the efficacy of these drugs.

CONCLUSIONS

We contend that opinions on the effectiveness of antidepressants should be reconsidered, and comparisons with placebo should be more carefully applied. Interpretation of the placebo response is of crucial importance for establishing the efficacy of antidepressive medications, and psychiatry should not become the hostage of placebo.

Definitions and factors associated with subthreshold depressive conditions: a systematic review

BACKGROUND

Subthreshold depressive disorders (minor and subthrehold depression) have been defined in a wide range of forms, varying on the number of symptoms and duration required. Disability associated with these conditions has also been reported. Our aim was to review the different definitions and to determine factors associated with these conditions in order to clarify the nosological implications of these disorders.

METHODS

A Medline search was conducted of the published literature between January 2001 and September 2011. Bibliographies of the retrieved papers were also analysed.

RESULTS

There is a wide heterogeneity in the definition and diagnostic criteria of minor and subthreshold depression. Minor depression was defined according to DSM-IV criteria. Regarding subthreshold depression, also called subclinical depression or subsyndromal symptomatic depression, between 2 and 5 depressive symptoms were required for the diagnosis, and a minimum duration of 2 weeks. Significant impairment associated with subthreshold depressive conditions, as well as comorbidity with other mental disorders, has been described.

CONCLUSIONS

Depression as a disorder is better explained as a spectrum rather than as a collection of discrete categories. Minor and subthreshold depression are common conditions and patients falling below the diagnostic threshold experience significant difficulties in functioning and a negative impact on their quality of life. Current diagnostic systems need to reexamine the thresholds for depressive disorders and distinguish them from ordinary feelings of sadness.

The drugs don't work? antidepressants and the current and future pharmacological management of depression

Depression is a potentially life-threatening disorder affecting millions of people across the globe. It is a huge burden to both the individual and society, costing over £9 billion in 2000 alone: the World Health Organisation (WHO) cited it as the third leading cause of global disability in 2004 (first in the developed world), and project it will be the leading cause by 2030. The serendipitous discovery of antidepressants has revolutionized both our understanding and management of depression: however, their efficacy in the treatment of depression has long been debated and recently been brought very much into the public limelight by a controversial publication by Kirsch, in which the role of placebo response in antidepressant efficacy trials is highlighted. Whilst antidepressants offer benefits in both the short and long term, important problems persist such as intolerability, delayed therapeutic onset, limited efficacy in milder depression and the existence of treatment-resistant depression.