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Prevalence of MTHFR C677T and MS A2756G polymorphisms in major depressive disorder, and their impact on response to fluoxetine treatment. CNS Spectr 2012; 17:76-86. [PMID: 22789065 PMCID: PMC4117348 DOI: 10.1017/s1092852912000430] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the prevalence of the C677T polymorphism of the methylene tetrahydrofolate reductase (MTHFR) gene and the A2756G polymorphism of methionine synthase (MS), and their impact on antidepressant response. METHODS We screened 224 subjects (52% female, mean age 39 ± 11 years) with SCID-diagnosed major depressive disorder (MDD), and obtained 194 genetic samples. 49 subjects (49% female, mean age 36 ± 11 years) participated in a 12-week open clinical trial of fluoxetine 20-60 mg/day. Association between clinical response and C677T and A2756G polymorphisms, folate, B12, and homocysteine was examined. RESULTS Prevalence of the C677T and A2756G polymorphisms was consistent with previous reports (C/C = 41%, C/T = 47%, T/T = 11%, A/A = 66%, A/G = 29%, G/G = 4%). In the fluoxetine-treated subsample (n = 49), intent-to-treat (ITT) response rates were 47% for C/C subjects and 46% for pooled C/T and T/T subjects (nonsignificant). ITT response rates were 38% for A/A subjects and 60% for A/G subjects (nonsignificant), with no subjects exhibiting the G/G homozygote. Mean baseline plasma B12 was significantly lower in A/G subjects compared to A/A, but folate and homocysteine levels were not affected by genetic status. Plasma folate was negatively associated with treatment response. CONCLUSION The C677T and A2756G polymorphisms did not significantly affect antidepressant response. These preliminary findings require replication in larger samples.
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Trinh NHT, Bedoya CA, Chang TE, Flaherty K, Fava M, Yeung A. A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression. BMC Psychiatry 2011; 11:166. [PMID: 21995514 PMCID: PMC3209439 DOI: 10.1186/1471-244x-11-166] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/13/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH). METHODS/DESIGN We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primary care providers' ability to provide appropriate, culturally informed care of depression, and b) patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identify which variables influenced patient participation in the program. DISCUSSION The study involves an innovative yet practical intervention that builds on existing resources and strives to improve quality of care for depression for minorities. Additionally, it complements the current movement in psychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention will serve as a model for care of Asian American and Latino American patients.
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Affiliation(s)
- Nhi-Ha T Trinh
- Depression and Clinical Research Program, Massachusetts General Hospital, Boston, USA.
| | - C A Bedoya
- Behavioral Medicine Service, Massachusetts General Hospital, One Bowdoin Square, seventh floor Boston, MA 02114, USA
| | - Trina E Chang
- Depression and Clinical Research Program, Massachusetts General Hospital, One Bowdoin Square, sixth floor Boston, MA 02114, USA
| | | | - Maurizio Fava
- Depression and Clinical Research Program, Massachusetts General Hospital, One Bowdoin Square, sixth floor Boston, MA 02114, USA
| | - Albert Yeung
- Depression and Clinical Research Program, Massachusetts General Hospital, One Bowdoin Square, sixth floor Boston, MA 02114, USA
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Fernández A, Pinto-Meza A, Bellón JA, Roura-Poch P, Haro JM, Autonell J, Palao DJ, Peñarrubia MT, Fernández R, Blanco E, Luciano JV, Serrano-Blanco A. Is major depression adequately diagnosed and treated by general practitioners? Results from an epidemiological study. Gen Hosp Psychiatry 2010; 32:201-9. [PMID: 20302995 DOI: 10.1016/j.genhosppsych.2009.11.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 11/18/2009] [Accepted: 11/19/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to (1) to explore the validity of the depression diagnosis made by the general practitioner (GP) and factors associated with it, (2) to estimate rates of treatment adequacy for depression and factors associated with it and (3) to study how rates of treatment adequacy vary when using different assessment methods and criteria. METHODS Epidemiological survey carried out in 77 primary care centres representative of Catalonia. A total of 3815 patients were assessed. RESULTS GPs identified 69 out of the 339 individuals who were diagnosed with a major depressive episode according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (sensitivity 0.22; kappa value: 0.16). The presence of emotional problems as the patients' primary complaint was associated with an increased probability of recognition. Rates of adequacy differed according to criteria: in the cases detected with the SCID-I interview, adequacy was 39.35% when using only patient self-reported data and 54.91% when taking into account data from the clinical chart. Rates of adequacy were higher when assessing adequacy among those considered depressed by the GP. CONCLUSION GPs adequately treat most of those whom they consider to be depressed. However, they fail to recognise depressed patients when compared to a psychiatric gold standard. Rates of treatment adequacy varied widely depending on the method used to assess them.
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Affiliation(s)
- Anna Fernández
- Sant Joan de Déu-SSM, Fundació Sant Joan de Déu, Barcelona, Spain.
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Manoleas P. Integrated primary care and behavioral health services for Latinos: a blueprint and research agenda. SOCIAL WORK IN HEALTH CARE 2008; 47:438-454. [PMID: 19042495 DOI: 10.1080/00981380802344480] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Disparities in Latino utilization of mental health services have been documented for some years. Factors such as stigma, low rates of health insurance, paucity of culturally competent providers, and linguistic inaccessibility have contributed to this underutilization. The documented tendency of many Latinos to experience the mind and body as a unified whole, often referred to as "non-dualism"; provides a unique opportunity to address these disparities in utilization. This article advocates a specific model of engagement of Latinos into a continuum of needed behavioral health services via the primary care clinic, and suggests a variety of clinical and administrative outcome measures for evaluating the effectiveness of the model. The model centers on the inclusion of a behavioral health specialist who is "nested" within the primary care team. The preparation and perspectives of clinically trained social workers make them ideal for this role.
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Affiliation(s)
- Peter Manoleas
- School of Social Welfare, University of California at Berkeley, Berkeley 94703, USA.
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Abstract
BACKGROUND In the past decade, in clinical psychiatry several investigations suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders. The aim of this paper was to illustrate the practical implications of sequential treatment strategy for depression in primary care, with particular reference to the increasingly common problem of recurrent depression. METHODS The Authors tried to integrate the evidence which derives from meta-analyses and comprehensive general reviews with the insights which derive from controlled studies concerned with specific populations. CONCLUSIONS The sequential treatment of mood disorders is an intensive, two-stage approach, which derives from the awareness that one course of treatment with a specific tool (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the affective disturbances of patients, both in research and in clinical practice settings. The aim of the sequential approach is to add therapeutic ingredients as long as they are needed. In this sense, it introduces a conceptual shift in clinical practice.
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Affiliation(s)
- C Rafanelli
- Department of Psychology, University of Bologna, Bologna, Italy.
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Van Voorhees BW, Walters AE, Prochaska M, Quinn MT. Reducing health disparities in depressive disorders outcomes between non-Hispanic Whites and ethnic minorities: a call for pragmatic strategies over the life course. Med Care Res Rev 2007; 64:157S-94S. [PMID: 17766647 DOI: 10.1177/1077558707305424] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There are significant disparities in treatment process and symptomatic and functional outcomes in depressive disorders for racial and ethnic minority patients. Using a life-course perspective, the authors conducted a systematic review of the literature to identify modifiable mechanisms and effective interventions for prevention and treatment at specific points -- system, community, provider, and individual patient -- in health care settings. Multicomponent chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions. Socioculturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs. Future research should focus on identifying key components of case management and sociocultural tailoring that are essential for effective interventions and developing new low-cost dissemination mechanisms for treatment and preventive programs that could be tailored to racial and ethnic minorities.
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Yeung A, Kung WW, Murakami JL, Mischoulon D, Alpert JE, Nierenberg AA, Fava M. Outcomes of recognizing depressed Chinese American patients in primary care. Int J Psychiatry Med 2006; 35:213-24. [PMID: 16480237 DOI: 10.2190/11da-xnqr-wyxr-agxk] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE This study aims to examine the effect of identifying Chinese American patients as having major depressive disorder (MDD) to their primary care physicians (PCPs) on the latter's attention given to the treatment of depression. METHODOLOGY Forty Chinese American patients from a primary care clinic were identified as having major depressive disorder (MDD), and their primary care physicians (PCPs) were notified of the diagnosis by letter. Three months later, medical records of subjects in the study were reviewed to see if their PCPs had intervened through referral and/or initiated treatment of depression. RESULTS PCPs documented intervention in 19 patients (47%) regarding their depression. Two of these patients (11%) were started on an antidepressant. Four (21%) accepted and 13 (68%) declined referral to mental health services. No intervention was recorded for 21 (53%) patients. CONCLUSION We conclude that recognition alone of MDD among Chinese Americans in the community primary care setting does not lead to adequate initiation of treatment for depression by PCPs.
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Affiliation(s)
- Albert Yeung
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, Massachusetts 02114, USA.
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Abstract
Major depressive disorder (MDD) is a highly prevalent disease, frequently characterized by recurrent or chronic course, and by comorbidity with other medical illnesses. The lifetime prevalence of MDD ranges up to 17% in the general population, and it almost doubles in patients with diabetes (9-27%), stroke (22-50%), or cancer (18-39%). Moreover, MDD worsens the prognosis, quality of life, and treatment compliance of patients with comorbid medical illnesses. Similar to what is observed with other comorbid illnesses, MDD worsens the outcome of kidney disease patients by increasing both morbidity and mortality. Treatment of depressive symptoms in renal failure patients increases medication acceptability and therefore potentially improves the overall patient outcome. The issue of the safety of antidepressant treatment in subjects with renal failure is frequently counterbalanced by the risks associated with depression comorbidity, provided that antidepressants with a low volume of distribution and low protein binding are prescribed, and most important, at low initial doses. Screening for CYP isoenzyme interactions with current medications is also recommended before starting antidepressant treatment.
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Affiliation(s)
- Eliana Tossani
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Fava GA, Ruini C, Sonino N. Treatment of recurrent depression: a sequential psychotherapeutic and psychopharmacological approach. CNS Drugs 2004; 17:1109-17. [PMID: 14661988 DOI: 10.2165/00023210-200317150-00005] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The chronic and recurrent nature of major depressive disorder is receiving increasing attention. Approximately eight of ten people experiencing a major depressive episode will have at least one more episode during their lifetime, i.e. recurrent major depressive disorder. In the 1990s, prolonged or lifelong pharmacotherapy emerged as the main therapeutic tool for preventing relapses of depression. This therapeutic approach is based on the effectiveness of antidepressant drugs compared with placebo in decreasing relapse risk and on the improved tolerability profile of the newer antidepressants compared with their older counterparts. However, outcome after discontinuation of antidepressant therapy does not seem to be affected by the duration of administration. Loss of clinical effects, despite adequate compliance, has also emerged as a vexing clinical problem. The use of intermittent pharmacotherapy with follow-up visits is an alternative therapeutic option. This leaves patients with periods free of drugs and adverse effects and takes into account that a high proportion of patients would discontinue the antidepressant anyway. However, the problems of resistance (that a drug treatment may be associated with a diminished chance of response in subsequent treatments in those patients whose symptoms successfully responded to it but who discontinued it) and of discontinuation syndromes are substantial disadvantages of this therapeutic approach. In recent years, several controlled trials have suggested that sequential use of pharmacotherapy in the treatment of the acute depressive episode and psychotherapy in its residual phase may improve long-term outcome. Patients, however, need to be motivated for psychotherapy, and skilled therapists have to be available. Despite an impressive amount of research into the treatment of depression, there is still a paucity of studies addressing the specific problems that prevention of recurrent depression entails. It is important to discuss with the patient the various therapeutic options and to adapt strategies to the specific needs of patients.
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Affiliation(s)
- Giovanni A Fava
- Affective Disorders Program, Department of Psychology, University of Bologna, Viale Berti Pichate 5, 40130, Italy.
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Smith RC, Korban E, Kanj M, Haddad R, Lyles JS, Lein C, Gardiner JC, Hodges A, Dwamena FC, Coffey J, Collins C. A method for rating charts to identify and classify patients with medically unexplained symptoms. PSYCHOTHERAPY AND PSYCHOSOMATICS 2004; 73:36-42. [PMID: 14665794 PMCID: PMC1993543 DOI: 10.1159/000074438] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND As part of conducting a randomized control trial (RCT) to treat chronically high utilizing patients with medically unexplained symptoms (MUS), we developed the chart rating method reported here to identify and classify MUS subjects. METHOD Intended at this point only as a research tool, the method is comprehensive, uses explicit guidelines, and requires clinician raters. It distinguishes primary organic disease patients from those with primary MUS, quantifies medical comorbidities in primary MUS patients, and also distinguishes subgroups among MUS patients that we call somatization (resembles DSM-IV somatoform disorders) and minor acute illness (MAI) which differs from DSM-IV somatoform definitions. Scoring rules are used to generate the diagnoses above. The rules may be set according to the investigator's needs, from highly sensitive to highly specific. RESULTS We found high levels of agreement with the gold standard for MUS vs. organic disease (97.6%) and among raters for the key individual chart elements rated (92-96%). The method identified 206 MUS subjects and the extent of their medical comorbidities for entry into a RCT. It also identified somatization and MAI; the latter supports the validity of this newly reported MAI syndrome. CONCLUSION We concluded that this method offered research potential for identifying MUS patients, for quantifying their medical comorbidities, and for classifying MUS subgroups.
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Affiliation(s)
- Robert C Smith
- Department of Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA.
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MacGregor MW, Davidson KW, Rowan P, Barksdale C, MacLean D. The use of defenses and physician health care costs: are physician health care costs lower in persons with more adaptive defense profiles? PSYCHOTHERAPY AND PSYCHOSOMATICS 2003; 72:315-23. [PMID: 14526134 DOI: 10.1159/000073028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The objective of the present study was to determine if persons who use more adaptive defenses have lower physician health care costs compared to those who use less adaptive defenses. METHODS We randomly selected 667 persons from the 1995 population-based Nova Scotia Health Survey who completed a videotaped structured interview. Each interview was rated for typical defense use by the Defense-Q. We obtained physician health care costs for 3 months before and after the interview, as well as medical diagnoses and measures of psychological functioning. RESULTS A more adaptive defense profile significantly predicted lower future physician health care costs. These results were found when controlling for other psychosocial variables, before and after controlling for previous physician health care costs, and when testing only within a physically healthy subsample. Results of secondary analyses showed that a more adaptive defense profile was positively related to a number of psychosocial variables, such as nurse's rating of competence, lack of depressive symptoms, and days at work. CONCLUSIONS The adaptiveness of a person's defense use in managing affect is important in predicting physician health care costs as well as psychosocial functioning.
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Fava GA, Ruini C. Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy. J Behav Ther Exp Psychiatry 2003; 34:45-63. [PMID: 12763392 DOI: 10.1016/s0005-7916(03)00019-3] [Citation(s) in RCA: 220] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article describes the main characteristics and technical features of a novel psychotherapeutic strategy, well-being therapy. This paper outlines the background of its development, the structure of well-being therapy, its key concepts and technical aspects. Well-being therapy is based on Ryff's multidimensional model of psychological well-being, encompassing six dimensions: autonomy, personal growth, environmental mastery, purpose in life, positive relations and self-acceptance. The goal of this therapy is improving the patients' levels of psychological well-being according to these dimensions, using cognitive-behavioral techniques. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive-behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological or psychotherapeutic treatments and in body image disturbances. The clinical studies supporting its efficacy are illustrated.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, Bologna 40127, Italy.
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Fava GA, Ruini C, Sonino N. Management of recurrent depression in primary care. PSYCHOTHERAPY AND PSYCHOSOMATICS 2003; 72:3-9. [PMID: 12466632 DOI: 10.1159/000067189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Affective Disorders Program, Departments of Psychology, University of Bologna, Bologna, Italy.
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Abstract
Depressive disorders are a significant public health issue. They are prevalent, disabling, often chronic illnesses, which cause a high economic burden for society, related to both direct and indirect costs. Depressive disorders also influence significantly the outcome of comorbid medical illnesses such as cardiac diseases, diabetes, and cancer. In primary care, underrecognition and undertreatment of depressive disorders are common, despite their relatively high prevalence, which accounts typically for more than 10% of patients. Primary care physicians should be aware of the common risk factors for depressive disorders such as gender, neuroticism, life events and adverse childhood experiences, and they should be familiar with associated features such as a positive psychiatric family history and prior depressive episodes. In primary care settings, depressive disorders should be considered with patients with multiple medical problems, unexplained physical symptoms, chronic pain or use of medical services that is more frequent than expected. Management of depressive disorders in primary care should include treatment with the newer antidepressant agents (given the fact they are typically well tolerated and safe) and focus on concomitant unhealthy behaviors as well as treatment adherence, which may both affect patient outcome. Programs aimed at improving patient follow-up and the coordination of the primary care intervention with that of specialists have been found to improve patient outcomes and to be cost effective.
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Affiliation(s)
- Paolo Cassano
- Depression Clinical and Research Program, Massachusetts General Hospital, 15 Parkman Street-ACC 812, , Boston, MA 02114, USA
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Fava M, Schmidt ME, Zhang S, Gonzales J, Raute NJ, Judge R. Treatment approaches to major depressive disorder relapse. Part 2: reinitiation of antidepressant treatment. PSYCHOTHERAPY AND PSYCHOSOMATICS 2002; 71:195-9. [PMID: 12097784 DOI: 10.1159/000063644] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anecdotal reports concerning mood disorder patients suggest restarting drug treatment in patients who prematurely discontinue it may be associated with a diminished chance of response upon rechallenge. We evaluated the likelihood of response to reinitiation of fluoxetine treatment in patients relapsing after switching to placebo during a long-term efficacy study of two different dosing regimens of fluoxetine. METHOD Patients who met the DSM-IV major depressive disorder criteria with modified HAMD17 scores > or =18 and CGI-Severity scores > or =4 were treated with open-label 20 mg/day fluoxetine for 13 weeks in a multicenter US study. Responders (n = 501) were randomized to placebo, 20 mg fluoxetine daily, or 90 mg enteric-coated fluoxetine weekly for 25 weeks of double-blind continuation treatment. Patients relapsing during the continuation phase were offered 25 weeks of double-blind rescue treatment during which the study medication dose was increased as follows: (1) patients on placebo had treatment with fluoxetine 20 mg/ day reinitiated; (2) patients on fluoxetine 20 mg/day had their dose increased to 40 mg/day, and (3) patients on a 90-mg weekly dose had their dose increased to 90 mg twice a week. Only the results of the rescue phase for the group who relapsed while on continuation treatment with placebo are reported here. Analyses included percentage of responders (50% reduction of modified HAMD17 and CGI-Severity < or =2) and assessments of change from baseline to endpoint (HAMD, CGI-Severity). Safety measures included assessment of vital signs, laboratory measures, and treatment-emergent adverse events. RESULTS Of 122 patients assigned to placebo, 57 (47%) relapsed during continuation treatment. Fifty-five (96%) of these elected to enter double-blind rescue treatment. Overall, patients who relapsed upon switching to placebo responded well to reinitiation of fluoxetine (62%). The mean modified HAMD17 score decreased from 20 to less than 9 and was maintained for up to 6 months. Thirty-eight percent of patients either did not respond or initially responded but again relapsed after reinitiation of medication. CONCLUSION This study suggests that patients who, after an initial response to fluoxetine, relapse upon switching to placebo have a relatively high probability of responding to the reinitiation of fluoxetine treatment. These results challenge the view that the efficacy of an agent prematurely discontinued is diminished when such an agent is restarted. They also generally support reinitiation of the same antidepressant as a 'first-line' treatment strategy in patients who relapsed after stopping a previously effective antidepressant.
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Affiliation(s)
- Maurizio Fava
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, Mass 02114, USA.
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Schmidt ME, Fava M, Zhang S, Gonzales J, Raute NJ, Judge R. Treatment approaches to major depressive disorder relapse. Part 1: dose increase. PSYCHOTHERAPY AND PSYCHOSOMATICS 2002; 71:190-4. [PMID: 12097783 DOI: 10.1159/000063643] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although continuing antidepressant treatment after patients have responded to medication has been shown to greatly reduce the risk of relapse, this risk is not eliminated. A number of theories have been proposed to account for this apparent loss of efficacy. A common initial approach to managing relapse is to increase the dose of antidepressant. We prospectively evaluated the likelihood of response to increasing the fluoxetine doses in patients relapsing during a long-term efficacy study of two fluoxetine dosing regimens. METHOD Patients meeting the DSM-IV criteria for major depressive disorder with modified HAMD17 scores > or =18 and CGI-severity scores > or =4 were treated for 13 weeks with open-label 20 mg/day fluoxetine in a multicenter US study. Responders (n = 501) were randomized to 20 mg fluoxetine daily, placebo, or 90 mg enteric-coated fluoxetine weekly for 25 weeks of double-blind continuation treatment. If the patients relapsed during the continuation phase, they were offered a 25-week optional rescue treatment phase during which the study medication dose was increased as follows: (1) patients on placebo had treatment with fluoxetine 20 mg/day reinitiated, (2) patients on fluoxetine 20 mg/day had their dose increased to 40 mg/day, and (3) patients on a 90-mg weekly dose had their dose increased to 90 mg twice a week. The results of the rescue phase for the latter two groups who relapsed while on continuation treatment with fluoxetine are reported. Response was defined as a 50% reduction in the modified HAMD17 score since time of relapse and a CGI-severity score < or =2. Additional efficacy analyses included HAMD and CGI-severity changes from baseline to endpoint. Safety measures included assessment of treatment-emergent adverse events, vital signs, and laboratory measures. RESULTS Overall, patients relapsing during the continuation treatment responded to an increased dose (57% of the 40-mg-daily group and 72% of the enteric-coated 90-mg-twice-weekly group). Mean modified HAMD17 scores decreased from a mean of approximately 20 to below 8 and were maintained for up to 6 months in the responders. Thirty-five percent of patients either did not respond or initially responded but again relapsed after augmentation of medication. CONCLUSIONS The patients relapsing after initially responding to fluoxetine can benefit from an increase in fluoxetine dose. These results also generally support increasing dose as a first-line treatment strategy for a patient who has relapsed while taking a previously effective dose of an antidepressant. Increasing enteric-coated fluoxetine 90 mg once weekly to twice weekly appeared to be as well-tolerated and effective in restoring response as increasing a daily fluoxetine dose from 20 to 40 mg.
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Affiliation(s)
- Mark E Schmidt
- Lilly Research Laboratories, Indianapolis, Ind 46285, USA
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Yeung A, Howarth S, Chan R, Sonawalla S, Nierenberg AA, Fava M. Use of the Chinese version of the Beck Depression Inventory for screening depression in primary care. J Nerv Ment Dis 2002; 190:94-9. [PMID: 11889362 DOI: 10.1097/00005053-200202000-00005] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Many Asian-Americans are unfamiliar with depression and its treatment. When depressed, they generally seek treatment from their primary care physicians and complain about their physical symptoms, resulting in under-recognition and under-treatment of depression. This study evaluates the effectiveness of the Chinese version of the Beck Depression Inventory (CBDI) for screening depression among Chinese-Americans in primary care. A total of 503 Chinese-Americans in the primary care clinic of a community health center were administered the CBDI for depression screening. Patients who screened positive (CBDI > or = 16) were interviewed by a psychiatrist using the Structured Clinical Interview for DSM-III-R, patient version (SCID-I/P) for confirmation of the diagnosis. Patients who screened negative (CBDI < 16) were randomly selected to be interviewed using the depression module of the SCID-I/P. The results of the SCID-I/P interview were used as the standard for evaluating the sensitivity and specificity of the CBDI. A total of 815 Chinese-Americans in a primary care clinic were approached, and 503 completed the CBDI. Seventy-six (15%) screened positive (CBDI > or = 16), and the prevalence of major depression was 19.6% by using extrapolated results from SCID-I/P interviews. When administered by a native-speaking research assistant, the CBDI has good sensitivity (.79), specificity (.91), positive predictive value (.79), and negative predictive value (.91). Despite the commonly believed tendency to focus on physical symptoms rather than depressed mood, Chinese-Americans are able to report symptoms of depression in response to a questionnaire. The CBDI, when administered by research assistants, has good sensitivity and specificity in recognizing major depression in this population. Lack of interest among Chinese-American patients in using the CBDI as a self-rating instrument has limited its use for depression screening in primary care settings.
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Affiliation(s)
- Albert Yeung
- Depression Clinical and Research Program, Massachusetts General Hospital, 50 Staniford St., Suite 401, Boston, Massachusetts 02114, USA
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