The Mortality and Myocardial Effects of Antidepressants Are Moderated by Preexisting Cardiovascular Disease: A Meta-Analysis

Current research progress, opportunities, and challenges of Limosillactobacillus reuteri-based probiotic dietary strategies

Limosillactobacillus reuteri (L. reuteri), a type of Lactobacillus spp., stands out as the most extensively researched probiotic. Its remarkable intestinal adhesion has led to widespread applications in both the food and medical sectors. Notably, recent research highlights the probiotic efficacy of L. reuteri sourced from breast milk, particularly in influencing social behavior and mitigating atopic dermatitis. In this review, our emphasis is on surveying recent literature regarding the promotion of host's health by L. reuteri. We aim to provide a concise summary of the latest regulatory effects and potential mechanisms attributed to L. reuteri in the realms of metabolism, brain- and immune-related functions. The mechanism through which L. reuteri promotes host health by modulating the intestinal microenvironment primarily involves promoting intestinal epithelial renewal, bolstering intestinal barrier function, regulating gut microbiota and its metabolites, and suppressing inflammation and immune responses. Additionally, this review delves into new technologies, identifies shortcomings, and addresses challenges in current L. reuteri research. Finally, the application prospects of L. reuteri are provided. Therefore, a better understanding of the role and mechanisms of L. reuteri will contribute significantly to the development of new probiotic functional foods and enable precise, targeted interventions for various diseases.

Understanding Australian general practice patients' decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach

OBJECTIVES

To evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying the mechanisms of the approach and (3) describing what contexts are associated with antidepressant tapering.

DESIGN

This mixed methods study was informed by the principles of realist evaluation and was conducted in the first 3 months of participation in the WiserAD randomised control trial.

SETTING

General practice, Victoria, Australia.

PARTICIPANTS

13 antidepressant users from general practice participating in the WiserAD trial for antidepressant deprescribing.

INTERVENTION

A patient-facing, web-based structured support tool that consists of a personalised tapering schedule, an action plan for managing withdrawal symptoms, a daily mood, sleep and activity tracker and mental health nurse support.

PRIMARY/SECONDARY OUTCOME MEASURES

The outcomes of the study were revealed on data analysis as per a realist evaluation approach which tests and refines an initial programme theory.

RESULTS

The contexts of learnt coping skills, knowledge and perceptions of antidepressants and feeling well were evident. Outcomes were intention to commence, initiation of deprescribing and successful completion of deprescribing. Key mechanisms for antidepressant deprescribing were (1) initiation of the deprescribing discussion; (2) patient self-efficacy; (3) provision of structured guidance; (4) coaching; (5) mood, sleep and activity tracking and (6) feelings of safety during the tapering period.

CONCLUSIONS

The WiserAD approach to antidepressant deprescribing supported participants to commence and/or complete tapering. The refined programme theory presents the WiserAD pragmatic framework for the application of antidepressant deprescribing in clinical practice.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT05355025; ACTRN12622000567729; ISRCTN11562922; Pre-results.

Patterns of filled prescriptions and the association with risk of drug-induced death. A population-based nested case-control register study

PURPOSE

Opioid analgesics (OA) and other pharmaceuticals have been associated with drug-induced deaths. However, there is a lack of knowledge regarding patterns of use of these pharmaceuticals in the population and regarding such associations. We identify and describe subgroups of people with different patterns of filled prescriptions of OA and other relevant pharmaceuticals and examine associations with drug-induced deaths. In addition, we estimate the proportion of drug-induced deaths with a filled OA prescription and OA as cause of death.

METHODS

A Norwegian population-based nested case-control register study with cases (drug-induced deaths 2010-2018, N = 2388) and population controls matched for age, gender and year of inclusion (N = 21 465). Patterns of filled prescriptions for opioid analgesics (OA), benzodiazepines and benzodiazepine-related drugs, gabapentinoids, ADHD medication and antidepressants/antipsychotics were explored by k-means cluster analysis. Associations with drug-induced deaths were estimated by conditional logistic regression adjusted for sociodemographic characteristics. Overlap of filled OA prescriptions and OA as cause of death was estimated.

RESULTS

Five clusters were identified: 'few prescriptions', 'weak OA', 'ADHD medication', 'sedative/psychiatric morbidity' and 'strong OA'. The 'strong OA' cluster had higher socioeconomic status compared to the other groupings. The risk of drug-induced death was also highest in this cluster (OR = 35.5; CI 25.6-49.3) and, for 68% (CI 64-73) of cases, filled prescriptions for OA was indicated as the underlying cause of death.

CONCLUSIONS

The cluster analysis identified a subgroup with filled prescriptions of OA and other pharmaceuticals and a higher socioeconomic status than other subgroups. This subgroup had a high risk of drug-induced death that needs to be addressed.

Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.

Objective

To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.

Data Sources

MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.

Study Selection

English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.

Main Outcomes and Measures

Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.

Results

For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.

Conclusions and Relevance

Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.

Predictors of successful discontinuation of antipsychotics and antidepressants

BACKGROUND

To offer support for patients who decide to discontinue antipsychotic and antidepressant medication, identifying which potentially modifiable factors correlate with discontinuation success is crucial. Here, we analyzed the predictive value of the professional support received, circumstances prior to discontinuation, a strategy of discontinuation, and use of functional and non-functional coping strategies during discontinuation on self-reported discontinuation success and on objective discontinuation.

METHODS

Patients who had attempted discontinuing antipsychotics (AP) and/or antidepressants (AD) during the past 5 years (n = 316) completed an online survey including questions on subjective and objective discontinuation success, sociodemographic, clinical and medication-related factors, and scales to assess the putative predictors.

RESULTS

A regression model with all significant predictors explained 20-30% of the variance in discontinuation success for AD and 30-40% for AP. After controlling for baseline sociodemographic, clinical and medication-related factors, the most consistent predictor of subjective discontinuation success was self-care behavior, in particular mindfulness, relaxation and making use of supportive relationships. Other predictors depended on the type of medication: For AD, good alliance with the prescribing physician predicted higher subjective success whereas gradual tapering per se was associated with lower subjective success and a lower chance of full discontinuation. In those tapering off AP, leaving time to adjust between dose reductions was associated with higher subjective success and fewer negative effects.

CONCLUSIONS

The findings can inform evidence-based clinical guidelines and interventions aiming to support patients during discontinuation. Further studies powered to take interactions between variables into account are needed to improve the prediction of successful discontinuation.

Antidepressant and antipsychotic drug prescribing and diabetes outcomes: A systematic review of observational studies

AIMS

Psychotropic medication may be associated with adverse effects, including among people with diabetes. We conducted a systematic review of observational studies investigating the association between antidepressant or antipsychotic drug prescribing and type 2 diabetes outcomes.

METHODS

We systematically searched PubMed, EMBASE, and PsycINFO to 15th August 2022 to identify eligible studies. We used the Newcastle-Ottawa scale to assess study quality and performed a narrative synthesis.

RESULTS

We included 18 studies, 14 reporting on antidepressants and four on antipsychotics. There were 11 cohort studies, one self-controlled before and after study, two case-control studies, and four cross-sectional studies, of variable quality with highly heterogeneous study populations, exposure definitions, and outcomes analysed. Antidepressant prescribing may be associated with increased risk of macrovascular disease, whilst evidence on antidepressant and antipsychotic prescribing and glycaemic control was mixed. Few studies reported microvascular outcomes and risk factors other than glycaemic control.

CONCLUSIONS

Studies of antidepressant and antipsychotic drug prescribing in relation to diabetes outcomes are scarce, with shortcomings and mixed findings. Until further evidence is available, people with diabetes prescribed antidepressants and antipsychotics should receive monitoring and appropriate treatment of risk factors and screening for complications as recommended in general diabetes guidelines.

Exploring the Role of Serotonin as an Immune Modulatory Component in Cardiovascular Diseases

Serotonin, also known as 5-hydroxytryptamine (5-HT) is a well-known neurotransmitter in the central nervous system (CNS), but also plays a significant role in peripheral tissues. There is a growing body of evidence suggesting that serotonin influences immune cell responses and contributes to the development of pathological injury in cardiovascular diseases, such as atherosclerosis, as well as other diseases which occur as a result of immune hyperactivity. In particular, high levels of serotonin are able to activate a multitude of 5-HT receptors found on the surface of immune cells, thereby influencing the process of atherosclerotic plaque formation in arteries. In this review, we will discuss the differences between serotonin production in the CNS and the periphery, and will give a brief outline of the function of serotonin in the periphery. In this context, we will particularly focus on the effects of serotonin on immune cells related to atherosclerosis and identify caveats that are important for future research.

Antidepressant Use and Risk of Myocardial Infarction: A Longitudinal Investigation of Sex-Specific Associations in the HUNT Study

OBJECTIVE

Antidepressants are thought to affect the risk of cardiovascular disease, although the nature of the association is unclear. Men and women have unique cardiovascular risk factors, and sex differences in depression as well as the efficacy of antidepressants are important to consider. We examined whether antidepressant use was associated with risk of having a myocardial infarction (MI) and whether this association was sex-specific.

METHODS

Data from The Trøndelag Health Study were used, gathered from a population in Norway ( N = 31,765), collected from 1995 to 2008. These data were combined with the Norwegian Cause of Death Registry and the Norwegian Prescription Database. We performed logistic regression models to examine the association of antidepressant use on risk of having a fatal or nonfatal MI, adjusting for depression, anxiety, diabetes, systolic blood pressure, cholesterol, waist-hip ratio, smoking, age, and sex. Results are presented as odds ratios (ORs) and 95% confidence intervals in parentheses.

RESULTS

The results indicated that antidepressant use was associated with a reduced risk of having MI at a later date (OR = 0.49 [0.38-0.64]). Although this association was somewhat stronger for women (OR = 0.46 [0.31-0.68]) compared with men (OR = 0.53 [0.37-0.75]), analysis did not identify a sex-specific association of antidepressant use on MI. Follow-up analyses on different subtypes of antidepressants showed that both selective serotonin reuptake inhibitor and tricyclic antidepressant were associated with a reduced risk of MI.

CONCLUSIONS

In this population study, the use of antidepressants was associated with a reduced risk of MI. This association was stronger for women, although we detected no interaction between sex and antidepressant use in terms of reduced risk of MI. Although limitations apply regarding causality, especially concerning a dose-response relationship, the results suggest that antidepressant use might reduce the risk of MI among both men and women.

Heart Rate Variability: A Measure of Cardiovascular Health and Possible Therapeutic Target in Dysautonomic Mental and Neurological Disorders

Mental illness such as depression and anxiety as well as cerebrovascular disease are linked to impairment of neurocardiac function mediated by changes to the autonomic nervous system with increased sympathetic and decreased parasympathetic activity. Autonomic neurocardiac function can be evaluated by computing heart rate variability (HRV). Over the past decades, research has demonstrated the diagnostic value of HRV as independent predictor of cardiovascular mortality and as disease marker in progressive autonomic nervous system disorders such as Parkinson’s disease. Here we summarize our studies on HRV and its therapeutic modulation in the context of psychopharmacology as well as psychiatric and neurological disorders to honor the life of Professor Evgeny Vaschillo, the true pioneer of HRV research who sadly passed away on November 21st, 2020.

Use of low-dose quetiapine increases the risk of major adverse cardiovascular events: results from a nationwide active comparator-controlled cohort study

At standard doses used for schizophrenia or bipolar disorder, quetiapine has been associated with weight gain and increased levels of triglycerides, to-tal cholesterol and low-density lipoprotein (LDL) cholesterol, which are risk factors for cardiovascular morbidity and mortality. However, this drug is also commonly used off-label at low doses for anxiolytic or hypnotic purposes, and its cardiovascular safety at these doses is unknown. We aimed to assess the risk of major adverse cardiovascular events with use of low-dose quetiapine compared to use of Z-drug hypnotics in a nationwide, active comparator-controlled cohort study. The cohort included new users of either drugs in Denmark from 2003 to 2017, aged 18-85 years, without history of ischemic stroke, myocardial infarction, cancer, and severe mental illness. The main outcome was the occurrence of major adverse cardiovascular events, defined as non-fatal myocardial infarction or ischemic stroke, or death from cardiovascular causes. Selective serotonin reuptake inhibitors (SSRIs) were used as an alternative comparator in sensitivity analyses. Altogether, we compared 60,566 low-dose quetiapine users with 454,567 Z-drug users, followed for 890,198 person-years in intent-to-treat analysis, and 330,334 person-years in as-treated analysis. In intention-to-treat analysis, low-dose quetiapine was associated with an increased risk of major adverse cardiovascular events (adjusted hazard ratio, aHR=1.13, 95% CI: 1.02-1.24, p=0.014) and cardiovascular death (aHR=1.26, 95% CI: 1.11-1.43, p<0.001). In as-treated analysis, continuous low-dose quetiapine use was associated with increased risk of major adverse cardiovascular events (aHR=1.52, 95% CI: 1.35-1.70, p<0.001), non-fatal ischemic stroke (aHR=1.37, 95% CI: 1.13-1.68, p=0.002) and cardiovascular death (aHR=1.90, 95% CI: 1.64-2.19, p<0.001). The risk of major adverse cardiovascular events was greater in women (aHR=1.28, p=0.02) and those aged ≥65 years at initiation (aHR=1.24, p<0.001). Compared to SSRIs, low-dose quetiapine use was associated with an increased risk of major adverse cardiovascular events (aHR=1.42, p<0.001), non-fatal ischemic stroke (aHR=1.27, p=0.0028) and cardiovascular death (aHR=1.72, p<0.001). So, we conclude that the use of low-dose quetiapine is associated with an increased risk of major adverse cardiovascular events, especially in women and the elderly. On the basis of these findings, we suggest that use of off-label low-dose quetiapine for sedative or hypnotic purposes should be discouraged.

Antidepressant use and risk of adverse outcomes: population-based cohort study

BACKGROUND

Antidepressants are one of the most widely prescribed drugs in the global north. However, little is known about the health consequences of long-term treatment.

AIMS

This study aimed to investigate the association between antidepressant use and adverse events.

METHOD

The study cohort consisted of UK Biobank participants whose data was linked to primary care records (N = 222 121). We assessed the association between antidepressant use by drug class (selective serotonin reuptake inhibitors (SSRIs) and 'other') and four morbidity (diabetes, hypertension, coronary heart disease (CHD), cerebrovascular disease (CV)) and two mortality (cardiovascular disease (CVD) and all-cause) outcomes, using Cox's proportional hazards model at 5- and 10-year follow-up.

RESULTS

SSRI treatment was associated with decreased risk of diabetes at 5 years (hazard ratio 0.64, 95% CI 0.49-0.83) and 10 years (hazard ratio 0.68, 95% CI 0.53-0.87), and hypertension at 10 years (hazard ratio 0.77, 95% CI 0.66-0.89). At 10-year follow-up, SSRI treatment was associated with increased risks of CV (hazard ratio 1.34, 95% CI 1.02-1.77), CVD mortality (hazard ratio 1.87, 95% CI 1.38-2.53) and all-cause mortality (hazard ratio 1.73, 95% CI 1.48-2.03), and 'other' class treatment was associated with increased risk of CHD (hazard ratio 1.99, 95% CI 1.31-3.01), CVD (hazard ratio 1.86, 95% CI 1.10-3.15) and all-cause mortality (hazard ratio 2.20, 95% CI 1.71-2.84).

CONCLUSIONS

Our findings indicate an association between long-term antidepressant usage and elevated risks of CHD, CVD mortality and all-cause mortality. Further research is needed to assess whether the observed associations are causal, and elucidate the underlying mechanisms.

Associations between illicit drug use in early adulthood and mortality: Findings from a National Birth Cohort

Illicit drug use is known to be associated with premature mortality. Whether exposure to socioeconomic disadvantage and mental health problems in childhood help to explain this association, is unclear. We analysed data from 11,250 participants in the 1970 British Birth Cohort study. At 10-years of age, socioeconomic disadvantage (parental socioeconomic position, material disadvantage, family disruption) and mental health problems with antisocial behaviour, attention, and anxiety were reported by mothers and teachers. At 30-years of age, study members provided information on their illicit drug use, exposure to socioeconomic disadvantage and mental health problems. At 30-years, 19.2% of participants had used an illicit drug in the past year. Mortality was elevated for eight of the twelve drugs assessed. Family disruption, maternal, and teacher assessments of antisocial behaviour at 10-years were associated with illicit drug use at 30-years. There was, however, very little change in these associations when exposure to childhood socioeconomic disadvantage (% change in hazard ratios [HR] 0-10%) or mental health problems (0.4-11.9%) were added to the sex-adjusted model. Adding exposure to socioeconomic disadvantage (0.8-38.9%) and mental health problems (31.7-74.1%) in adulthood to the sex-adjusted model resulted in marked attenuation in HRs for all drugs. These findings imply that interventions which provide opportunities for education, employment and access to effective mental health treatments in early adulthood may help to reduce mortality among drug users.

Polysubstance use poisoning deaths in Canada: an analysis of trends from 2014 to 2017 using mortality data

Background

Over the past decade, rates of drug poisoning deaths have increased dramatically in Canada. Current evidence suggests that the non-medical use of synthetic opioids, stimulants and patterns of polysubstance use are major factors contributing to this increase.

Methods

Counts of substance poisoning deaths involving alcohol, opioids, other central nervous system (CNS) depressants, cocaine, and CNS stimulants excluding cocaine, were acquired from the Canadian Vital Statistics Death Database (CVSD) for the years 2014 to 2017. We used joinpoint regression analysis and the Cochrane-Armitage trend test for proportions to examine changes over time in crude mortality rates and proportions of poisoning deaths involving more than one substance.

Results

Between 2014 and 2017, the rate of substance poisoning deaths in Canada almost doubled from 6.4 to 11.5 deaths per 100,000 population (Average Annual Percent Change, AAPC: 23%, p < 0.05). Our analysis shows this was due to increased unintentional poisoning deaths (AAPC: 26.6%, p < 0.05) and polysubstance deaths (AAPC: 23.0%, p < 0.05). The proportion of unintentional poisoning deaths involving polysubstance use increased significantly from 38% to 58% among males (p < 0.0001) and 40% to 55% among females (p < 0.0001). Polysubstance use poisonings involving opioids and CNS stimulants (excluding cocaine) increased substantially during the study period (males AAPC: 133.1%, p < 0.01; females AAPC: 118.1%, p < 0.05).

Conclusions

Increases in substance-related poisoning deaths between 2014 and 2017 were associated with polysubstance use. Increased co-use of stimulants with opioids is a key factor contributing to the epidemic of opioid deaths in Canada.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12678-z.

The combined effect of psychodynamic psychotherapy and pharmacotherapy on healthcare cost

OBJECTIVE

Previous studies have established a connection between therapy and healthcare cost: an increase in cost prior to therapy and a maintained decrease post therapy. There is, however, a lack of studies examining the combined effects of psychotherapy and pharmacotherapy on healthcare cost.

METHOD

Healthcare cost was examined quarterly in 1,213 patients (28,776 observations) in a naturalistic longitudinal design. Psychotherapy only was compared to combined treatment and to an addition of psychotherapy to preexisting pharmacotherapy. The comparisons were conducted with a multilevel piecewise model (LMLM) computed for three phases: pre-, during-, and post-therapy.

RESULTS

Significant interactions were found between the contrast comparing preexisting pharmacotherapy to the during-psychotherapy and no-pharmacotherapy groups and the three piecewise variables. The pre-therapy increase was larger for the preexisting-pharmacotherapy group than for the other groups. The during-therapy decrease was larger for the preexisting-pharmacotherapy group than for the other groups. In the post-therapy period, the increase was significant only for the prior-psychiatric-medication group.

CONCLUSIONS

Preexisting psychotropic treatment along with an increase in healthcare expenditure may serve as an indication of the need for additional psychotherapy treatment.

Placebo nasal spray protects female participants from experimentally induced sadness and concomitant changes in autonomic arousal

BACKGROUND

To investigate the powerful placebo effects in antidepressant drug trials and their mechanisms, recent pioneering experimental studies showed that expectation manipulation combined with an active placebo attenuated induced sadness. In the present study, we aimed at extending these findings by assessing the psychophysiological response in addition to mere self-report.

METHODS

One hundred and thirteen healthy female students were randomly assigned to a drug expectation group (active placebo, positive treatment expectation), placebo expectation group (active placebo, no treatment expectation), or a no-treatment group (no placebo, no treatment expectation). After placebo intake, sadness was induced by self-deprecating statements using the Velten method combined with sad music, including a rumination phase. Sadness was measured using the Positive and Negative Affect Schedule Expanded Form (PANAS-X). Heart rate and skin conductance were assessed continuously.

RESULTS

After mood induction and after rumination, self-reported sadness was significantly lower, and skin conductance level was significantly higher, in the drug expectation group than in the no-treatment group. The mood induction was further accompanied by a heart rate deceleration within all groups.

LIMITATIONS

Generalizability is limited by sample selectivity and focusing on sadness as a symptom of depression, exclusively.

CONCLUSION

Expectation-induced placebo effects significantly influenced sadness-correlated changes in autonomic arousal, and not only subjectively reported sadness, indicating that placebo effects in the context of affect are not merely due to subjective response bias. The systematic modification of treatment expectation could be utilized in clinical practice to optimize current therapeutic approaches to improve mood regulation.

Time to Update Evidence-Based Guideline Recommendations About Concurrent Tamoxifen and Antidepressant Use? A Systematic Review

Concerns around pharmacological interaction between tamoxifen and antidepressants have resulted in evidence-base guidelines that recommend avoidance or caution with concurrent use. It remains unclear however whether this interaction is clinically important. A systematic review of studies comparing endocrine therapy (including tamoxifen and aromatase inhibitors) alone or concurrent with antidepressants in breast cancer patients was performed. The literature search sought studies within MEDLINE, EMBASE, and the Cochrane Collaboration Library published from database inception until December 1, 2020. Outcomes of interest included recurrence, breast cancer-specific survival, overall mortality, quality of life, and treatment compliance. Studies were assessed with the Cochrane Risk of Bias tool for randomized controlled trials and the Newcastle Ottawa tool for case-control and cohort studies. From 695 citations, we included 15 studies (2 randomized controlled trials [255 patients], 10 retrospective cohort studies [75,678 patients], and 3 case-control studies [18,836 patients]). While between-study clinical and methodologic differences (including analysis of confounding variables) precluded formal meta-analysis, findings from included studies did not find consistent evidence that concurrent use of antidepressants (including paroxetine) with tamoxifen therapy has negative impacts on the outcomes of interest. In this systematic review, despite data from nearly 100,000 patients, concurrent use of tamoxifen and antidepressants showed no consistent negative effect on clinical outcomes. Given the recognized harm to patients of changing either endocrine therapy or antidepressants to avoid concurrent use, current evidence-based guidelines should be updated accordingly. More rigorously designed pharmacoepidemiologic studies are needed.

Metabolic Acidosis in Multi Drug Poisoning with Antidepressants and Antipsychotics

Objective:

In this study, we evaluated the predictive factors for the occurrence of metabolic acidosis in patients with multi-drug poisoning, including antidepressants (Ad)/antipsychotics (Ap).

Methods:

This cross-sectional study was carried out in the referral poisoning center, Khorshid University Hospital, affiliated with Isfahan University of Medical Sciences. All patients with multi-drug ingestion, including Ad/Ap, were included in the study. Patients were divided into two groups with and without metabolic acidosis. Demographic factors, time from ingestion to admission, clinical manifestations, length of hospital stay, and outcome were compared in two groups. Binary logistic regression was used to identify factors associated with the risk of metabolic acidosis occurrence.

Findings:

Among the 206 evaluated patients, 45 patients (21.8%) had metabolic acidosis whom the majority were female (73.3%) with intentional purposes (77.8%). 31.1% of the patients with metabolic acidosis had tachycardia on admission (P = 0.03). Among all variables, time from ingestion to admission (P = 0.02) and lengths of hospital stay (P = 0.002) were significantly different between patients with and without metabolic acidosis. Tachycardia on admission (adjusted odds ratio [OR], 2.24; 95% confidence interval [CI]: 1.05–4.76; P = 0.036) and time from ingestion to admission (adjusted OR, 1.06; 95% CI: 1.00–1.13; P = 0.04) were also the predictive factors in occurrence of metabolic acidosis. Most of the patients survived without any complications (94.6%), of whom 72.3% had no previous underlying somatic diseases (P = 0.05).

Conclusion:

Admission tachycardia and the time elapsed from ingestion to admission may be considered important factors for predicting metabolic acidosis in multi-drug poisoning, including Ad/Ap.

Efficacy of antidepressant drugs in the treatment of depression in Alzheimer disease patients: A systematic review and network meta-analysis

BACKGROUND

Depression is considered as one of the most common neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) patients. Prescription of antidepressants is a current clinical practice well-established as the first-line treatment for such patients. Our study was aimed at systematically examining the evidence on the efficacy of antidepressants in the treatment of depression in AD patients.

METHODS

We conducted a network meta-analysis of randomized controlled trials retrieved by systematic search of the Cochrane Central Register of Controlled Trials, PubMed, Embase, and CNKI databases. Primary outcomes included mean depression score and safety. Secondary outcomes were cognition. The surface under the cumulative ranking curve was performed to estimate a ranking probability for different treatments.

RESULTS

A total of 25 studies including 14 medications met the inclusion criteria. Compared with placebo, only mirtazapine (standard mean deviation [SMD], -1.94; 95% confidence interval [CI], -3.53 to -0.36; p < 0.05) and sertraline (SMD, -1.16; 95% CI, -2.17 to -0.15; p < 0.05) showed a slightly better effect in treating symptoms of depression. Clomipramine increased risk of adverse events than placebo (odds ratio, 3.01; 95% CI, 1.45 to 4.57; p < 0.05). In terms of cognitive function, there was no statistically significant difference between antidepressants and placebo.

CONCLUSION

Overall, in the short-term treatment, these data suggest that commonly used antidepressants sertraline and mirtazapine should be considered as an alternative treatment for depression in AD patients. However, more high-quality trials with large samples and longer following-up are proposed.

Cognitive Behavior Therapy for Depression From an Evolutionary Perspective

Evolutionary medicine attempts to solve a problem with which traditional medicine has struggled historically; how do we distinguish between diseased states and "healthy" responses to disease states? Fever and diarrhea represent classic examples of evolved adaptations that increase the likelihood of survival in response to the presence of pathogens in the body. Whereas, the severe mental disorders like psychotic mania or the schizophrenias may involve true "disease" states best treated pharmacologically, most non-psychotic "disorders" that revolve around negative affects like depression or anxiety are likely adaptations that evolved to serve a function that increased inclusive fitness in our ancestral past. What this likely means is that the proximal mechanisms underlying the non-psychotic "disorders" are "species typical" and neither diseases nor disorders. Rather, they are coordinated "whole body" responses that prepare the individual to respond in a maximally functional fashion to the variety of different challenges that our ancestors faced. A case can be made that depression evolved to facilitate a deliberate cognitive style (rumination) in response to complex (often social) problems. What this further suggests is that those interventions that best facilitate the functions that those adaptations evolved to serve (such as rumination) are likely to be preferred over those like medications that simply anesthetize the distress. We consider the mechanisms that evolved to generate depression and the processes utilized in cognitive behavior therapy to facilitate those functions from an adaptationist evolutionary perspective.

Repeated use of SSRIs potentially associated with an increase on serum CK and CK-MB in patients with major depressive disorder: a retrospective study

There is a large amount of evidence that selective serotonin reuptake inhibitors (SSRIs) are related to cardiovascular toxicity, which has aroused concern regarding their safety. However, few studies have evaluated the effects of SSRIs on cardiac injury biomarkers, such as creatine kinase (CK) and creatine kinase isoenzyme (CK-MB). The purpose of our study was to determine whether SSRIs elevated CK and CK-MB levels of prior medicated depressive patients (PMDP) compared to first-episode drug-naïve depressive patients (FDDPs). We performed an observational and retrospective study involving 128 patients with major depressive disorder. Patients who had never used any type of antidepressant were designated FDDP; patients who had used only one type of SSRI but were not treated after a recent relapse were designated PMDP. Serum CK and CK-MB levels were measured before and after using SSRIs for a period of time. The duration of current treatment in the FDDP and PMDP groups was 16.200 ± 16.726 weeks and 15.618 ± 16.902 weeks, respectively. After SSRI treatment, levels of serum CK in the PMDP group were significantly higher than in the FDDP group. Univariate ANCOVA results revealed that PMDP was 22.313 times more likely to elevate CK (OR 22.313, 95% CI 9.605-35.022) and 2.615 times more likely to elevate CK-MB (OR 2.615, 95% CI 1.287-3.943) than FDDP. Multivariate ANCOVA revealed an interaction between the group and sex of CK and CK-MB. Further pairwise analysis of the interaction results showed that in female patients, the mean difference (MD) of CK and CK-MB in PMDP was significantly greater than that in FDDP (MD = 33.410, P = 0.000, 95% CI 15.935-50.886; MD = 4.613, P = 0.000, 95% CI 2.846-6.381). Our findings suggest that patients, especially females, who had previously used SSRI antidepressants were more likely to have elevated CK and CK-MB, indicators of myocardial muscle injury. Use of SSRIs should not be assumed to be completely safe and without any cardiovascular risks.

Risk of infection within 4 weeks of corticosteroid injection (CSI) in the management of chronic pain during a pandemic: a cohort study in 216 patients

OBJECTIVES

Targeted corticosteroid injections (CSI) are one of the treatments that can provide pain relief and thereby, enhance quality of life in patients with chronic pain. Corticosteroids (CS) are known to impair immune response. The objective was to evaluate the risk of developing post-procedural infection within 4 weeks of receiving depot CSI for chronic pain as part of on going quality improvement project. We hypothesised that interventional treatment with depot steroids will not cause a significant increase in clinical infection in the first 4 weeks.

METHODS

Telephone follow-up was performed as a part of prospective longitudinal audit in a cohort of patients who received interventional treatment for chronic pain at a multidisciplinary pain medicine centre based at a university teaching hospital. Patients who received interventional treatment in the management of chronic pain under a single physician between October 2019 and December 2020 were followed up over telephone as part of on going longitudinal audits. Data was collected on any infection within 4 and 12 weeks of receiving the intervention. Outcomes collected included type of intervention, dose of depot steroids and pain relief obtained at 12 weeks following intervention.

RESULTS

Over a 15 month period, 261 patients received pain interventions with depot CS. There was no loss to follow-up. Nine patients reported an infection within 4 weeks of receiving depot steroids (9/261, 3.4%). None of the patients tested positive for Covid-19. Eight patients (8/261, 3%) reported an infection between 5 and 12 weeks following the corticosteroid intervention. Although none of the patients tested positive for Covid-19, two patients presented with clinical and radiological features suggestive of Covid-19. Durable analgesia was reported by 51% (133/261) and clinically significant analgesia by 30% (78/261) at 12 weeks following the intervention. Failure rate was 19% (50/261).

CONCLUSIONS

Pain medicine interventions with depot steroids do not appear to overtly increase the risk for Covid-19 infection in the midst of a pandemic.

Antidepressants and Risk of Sudden Cardiac Death: A Network Meta-Analysis and Systematic Review

Background: Antidepressants are one of the most prescribed medications, particularly for patients with mental disorders. Nevertheless, there are still limited data regarding the risk of ventricular arrhythmia (VA) and sudden cardiac death (SCD) associated with these medications. Thus, we performed systemic review and meta-analysis to characterize the risks of VA and SCD among patients who used common antidepressants. Methods: A literature search for studies that reported risk of ventricular arrhythmias and sudden cardiac death in antidepressant use from MEDLINE, EMBASE, and Cochrane Database from inception through September 2020. A random-effects model network meta-analysis model was used to analyze the relation between antidepressants and VA/SCD. Surface Under Cumulative Ranking Curve (SUCRA) was used to rank the treatment for each outcome. Results: The mean study sample size was 355,158 subjects. Tricyclic antidepressant (TCA) patients were the least likely to develop ventricular arrhythmia events/sudden cardiac deaths at OR 0.24, 0.028–1.2, OR 0.32 (95% CI 0.038–1.6) for serotonin and norepinephrine reuptake inhibitors (SNRI), and OR 0.36 (95% CI 0.043, 1.8) for selective serotonin reuptake inhibitors (SSRI), respectively. According to SUCRA analysis, TCA was on a higher rank compared to SNRI and SSRI considering the risk of VA/SCD. Conclusion: Our network meta-analysis demonstrated the low risk of VA/SCD among patients using antidepressants for SNRI, SSRI and especially, TCA. Despite the relatively lowest VA/SCD in TCA, drug efficacy and other adverse effects should be taken into account in patients with mental disorders.

A rating scale to inform successful discontinuation of antipsychotics and antidepressants

Practitioners lack guidance on how to support discontinuation of psychotropic medication. An understanding of what constitutes discontinuation success that encompasses the patients' perspective could advance knowledge in this clinically relevant area. Here, we report the development and validation of a scale to assess subjective discontinuation success. Participants who attempted discontinuing antidepressants and/or antipsychotics during the past 5 years (n = 396) completed a questionnaire on subjective discontinuation success (Discontinuation Success Scale, DSS) developed in consultation with people with lived experience of discontinuation. Construct validity was tested by exploratory and confirmatory factor analysis. Criterion validity was tested by assessing DSS-scores' associations with objective success (i.e., full cessation, reduced dose) in combination with scoring above a predefined criterion on the Well-Being Index. Factor analyses yielded a three-dimensional scale reflecting subjective discontinuation success, positive effects, and negative effects of discontinuation. A 24-item DSS demonstrated sufficient model fit for the participants discontinuing antidepressants or antipsychotics, respectively. Significant associations with objective success and well-being were found. Participants who had achieved full cessation and scored high on well-being reached the highest DSS scores. The DSS is a viable tool for future research aimed at identifying predictors of discontinuation success in order to inform recommendations related to discontinuation.

Evolutionary theory and the treatment of depression: It is all about the squids and the sea bass

According to the analytical rumination hypothesis, depression is an evolved adaptation (like pain or anxiety) that served in our ancestral past to keep people focused on complex interpersonal problems until they could arrive at a resolution (spontaneous remission). If this is true, then those clinical treatments that most facilitate the functions that depression evolved to serve are likely to be more advantageous in the long run than others that simply relieve distress. For example, antidepressant medications may be efficacious in the treatment of depression but only work for so long as they are taken. They may also have an iatrogenic effect that prolongs the duration of the underlying episode. Cognitive and behavioral interventions are as efficacious as medications in terms of reducing acute distress and also appear to have an enduring effect that protects against the return of subsequent symptoms. However, the bulk of the evidence for this effect comes from comparisons to prior medication treatment and it remains unclear whether these psychosocial interventions are truly preventative, or antidepressant medications iatrogenic. A study is described that could resolve this issue and test evolutionary theory with respect to the purported role of rumination in bringing about spontaneous remission.

Fentanyl Infusion Is Effective in the Treatment of Dyspnea in End-Stage Heart Failure With Renal Failure: A Case Report

Patients with end-stage heart failure may require hospitalization for the treatment of respiratory distress. Morphine may be used to relieve symptoms. However, use of morphine is problematic because heart failure is often associated with renal dysfunction. In this case report, intravenous fentanyl infusion reduced dyspnea in a patient with end-stage heart failure who was on dialysis induction to treat renal failure. The patient was able to eat and sleep after administration of an intravenous fentanyl solution and experienced no apparent respiratory depression as a side effect of fentanyl. There have been few reports of dyspnea relief with fentanyl infusion. Because of its adjustable duration of effect, intravenous fentanyl may be a more effective and useful option than rapid or extended-release agents in cases such as this one.

Impact of Antidepressants on Cardiac Events and All-Cause Mortality in Parkinson's Disease: A National Data-Linkage Study

PURPOSE

This study investigated the 1-year risk of ischemic heart disease (IHD), all cardiovascular events, and all-cause mortality among newly diagnosed Parkinson's disease (PD) patients who used antidepressants compared to those who did not.

PATIENTS AND METHODS

Patients with PD aged 40 years or older were identified using data from 2000 through 2016 held within the Welsh Secure Anonymized Information Linkage (SAIL) databank. Antidepressant users were propensity-score matched 1:1 with non-users, adjusting for patients' demographics, socioeconomic status, and multiple comorbidities. Cox proportional hazard regression analyses were performed to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between the antidepressants and the study outcomes. The follow-up period was 1 year after the initial prescription of antidepressants.

RESULTS

The study group comprised a total of 3364 participants, with numbers split equally between the antidepressant-user and non-user groups, based on the propensity score-matching process. Overall, the propensity score-adjusted model showed that antidepressant usage in PD patients was not significantly associated with the risk of IHD (HR = 1.05; 95% CI 0.63-1.75) or all cardiovascular events (HR = 1.01; 95% CI 0.71-1.45) compared to non-users. The propensity score-adjusted model also showed that the use of any antidepressant, regardless of its category, was not statistically significantly associated with all-cause mortality (HR = 0.81; 95% CI 0.65-1.02). However, this association reached statistical significance in the multivariate adjusted model (HR = 0.67; 95% CI 0.54-0.84).

CONCLUSION

There was no evidence that antidepressant use was associated with an increased risk of IHD or all cardiovascular events in newly diagnosed PD patients who suffered from depression. Furthermore, antidepressant use might reduce the mortality rate in PD patients during the first year after initiation.

Treatment of Heart Failure Patients with Anxiolytics Is Associated with Adverse Outcomes, with and without Depression

BACKGROUND

Few studies have evaluated the effect of pharmacologic treatment of anxiety on outcomes in heart failure (HF) patients. This study examined the impact of treatment with anxiolytics on clinical outcomes in a real-world sample of HF patients with and without depression.

METHODS

Patients diagnosed with HF were retrieved from a large HMO database. Patients prescribed anxiolytic medication and patients diagnosed with depression and/or prescribed anti-depressant medication were followed for cardiac-related hospitalizations and death.

RESULTS

The study cohort included 6293 HF patients. Treatment with anxiolytics was associated with decreased one-year survival compared to untreated individuals, with a greater reduction in survival seen in patients diagnosed with depression and/or treated with anti-depressants. Multi-variable analysis adjusting for age, sex, NYHA class, cardiac risk factors and laboratory parameters found that treatment with anxiolytics remained a predictor of mortality even when adjusting for depression. Depression combined with anxiolytic treatment was predictive of increased mortality, and treatment with anxiolytics alone, depression alone and anxiolytic treatment together with depression were each associated with an increased hazard ratio for a composite outcome of death and hospitalization.

CONCLUSIONS

In this real-world study of HF patients, both treatment with anxiolytics and depression were associated with increased mortality, and anxiolytic therapy remained a predictor of mortality when adjusting for depression. Treatment of anxiety together with depression was associated with the highest risk of mortality. Safe and effective treatment for anxiety and depression is warranted to alleviate the detrimental impact of these disorders on quality and of life and adverse events.

Criterion-related validity in a sample of migraine outpatients: the diagnostic criteria for psychosomatic research

OBJECTIVE

The Diagnostic Criteria for Psychosomatic Research (DCPR) are those of psychosomatic syndromes that did not find room in the classical taxonomy. More recently, the DCPR were updated, called DCPR-revised (DCPR-R). The present study was conducted to test the criterion-related validity of the DCPR-R.

METHODS

Two hundred consecutive subjects were enrolled at the Headache Center of Careggi University Hospital (Italy): 100 subjects had a diagnosis of chronic migraine (CM) and 100 had a diagnosis of episodic migraine (EM). Participants received a clinical assessment, which included the DCPR-revised Semi-Structured Interview (DCPR-R SSI), the Structured Clinical Interview for DSM-5 (SCID-5), and the psychosocial index (PSI).

RESULTS

Forty-seven subjects (23.5%) had at least one DSM-5 diagnosis: major depressive disorder (8.5%; n = 17) and agoraphobia (7.5%; n = 15) were the most frequent. One hundred and ten subjects (55%) reported a DCPR-R diagnosis: allostatic overload (29%; n = 58) and type A behavior (10.5%; n = 21) were the most frequent. When the incremental validity of the DCPR system over the DSM system was tested using PSI subscales as the criterion variable, the DCPR-R increased up to 0.11-0.24 the amount of explained variance. Subjects with at least one DCPR-R diagnosis showed lower PSI well-being scores (p = .001), higher PSI stress scores (p < .001), and higher PSI psychological distress scores (p = .008) than subjects without a DCPR-R diagnosis.

CONCLUSION

The DCPR-R showed a good criterion-related validity in migraine outpatients. Thus, they might be implemented, together with the DSM-5, in the assessment of migraine subjects.

Implementing Mobile HRV Biofeedback as Adjunctive Therapy During Inpatient Psychiatric Rehabilitation Facilitates Recovery of Depressive Symptoms and Enhances Autonomic Functioning Short-Term: A 1-Year Pre-Post-intervention Follow-Up Pilot Study

OBJECTIVE

New treatment options for depression are warranted, due to high recurrence rates. Recent research indicates benefits of heart rate variability biofeedback (HRVBF) on symptom recovery and autonomic functioning in depressed individuals. Slow-paced breathing-induced amplification of vagus nerve activity is the main element of HRVBF. Thus, the latter represents a safe and non-invasive complementary depression treatment. However, its efficacy in patients undergoing inpatient psychiatric rehabilitation receiving highly comprehensive treatments has not been evaluated.

METHODS

Ninety-two inpatients were randomly assigned to an intervention group (IG) or control group (CG). While the latter received the standard treatment only, adjunctive HRVBF was provided to the IG over 5 weeks. Depression severity and heart rate variability (HRV) were assessed before (pre) and after 5 weeks (post). Moreover, 1-year follow-up depression scores were available for 30 participants.

RESULTS

Although depression improved in both groups, the IG exhibited significantly larger improvements at post-assessment ( η p 2 = 0.065) and significant increases in resting LF-HRV (d = 0.45) and cardiorespiratory coherence (d = 0.61). No significant effects for RMSSD, SDNN, HF-HRV, or HR were found (ps > 0.05). Additionally, the IG showed a medium- to large-sized reduction in resting respiratory rate from 13.2 to 9.8 breaths per minute (p < 0.001, d = 0.86), with the CG exhibiting only a small decrease from 13.5 to 12.4 (p = 0.49; d = 0.35). While the IG exhibited significantly lower depression scores at post-assessment (p = 0.042, d = 0.79), this effect decreased during follow-up (p = 0.195, d = 0.48).

CONCLUSION

HRVBF as adjuvant therapy during inpatient psychiatric rehabilitation facilitated depression recovery. Additionally, amplified LF-HRV as well as cardiorespiratory coherence at rest and a decrease in resting breathing frequency was observed in the HRVBF group. These findings emphasize HRVBF's value as complementary therapy regardless of concurrent treatments. Moreover, these incremental benefits could serve as resource even after the actual training period. However, the additional antidepressant gains vanish during the long-term follow-up, indicating the need for more intense training or regular practice afterward, respectively. Thus, future studies are warranted to examine how the initial benefits of HRVBF during inpatient psychiatric rehabilitation can be preserved post discharge.

Prevalence, 12-Month Prognosis, and Clinical Management Need of Depression in Coronary Heart Disease Patients: A Prospective Cohort Study

BACKGROUND

Screening for depression in patients with coronary heart disease (CHD) remains controversial. There is limited data on the actual depression management need in routine care. The aim of this study was to examine the prevalence, treatment rates, prognosis, and management need of clinical and subclinical depression in CHD patients according to the American Heart Association recommendations and the National Institute for Health and Care Excellence (NICE) guideline "Depression in Adults with a Chronic Physical Health Problem".

METHODS

Patients were recruited at 2 German university clinics between 2012 and 2014. Depressive disorders were assessed according to the DSM-IV and depressive symptom severity at baseline and during follow-up was evaluated with the Patient Health Questionnaire (PHQ-9). Depression management need was determined by the severity and longitudinal course of depression symptoms.

RESULTS

Of 1,024 patients (19% women), 12% had clinical depression (depressive disorder) and 45% had subclinical depression (PHQ-9 score ≥5) at baseline. Among those with clinical depression, 46% were in treatment at least once during 12 months; 26% were continuously in treatment during follow-up. Depressive disorder and depressive symptoms were significant risk factor-adjusted predictors of the 12-months mortality (adjusted HR = 3.19; 95% CI 1.32-7.69, and adjusted HR = 1.09; 95% CI 1.02-1.16, respectively). Depressive symptoms persisted in 85% of the clinically depressed and in 47% of the subclinically depressed patients. According to current recommendations, 29% of all CHD patients would require depression management within 1 year.

CONCLUSIONS

There is a need for enhanced recognition, referral, and continuous and improved clinical management of depression in CHD patients.

Antidepressant treatment for primary care patients with depressive symptoms: Data from the diamond longitudinal cohort study

BACKGROUND

In light of emerging evidence questioning the safety of antidepressants, it is timely to investigate the appropriateness of antidepressant prescribing. This study estimated the prevalence of possible over- and under-treatment with antidepressants among primary care attendees and investigated the factors associated with potentially inappropriate antidepressant use.

METHODS

In all, 789 adult primary care patients with depressive symptoms were recruited from 30 general practices in Victoria, Australia, in 2005 and followed up every 3 months in 2006 and annually from 2007 to 2011. For this study, we first assessed appropriateness of antidepressant use in 2007 at the 2-year follow-up to enable history of depression to be taken into account, providing 574 (73%) patients with five yearly assessments, resulting in a total of 2870 assessments. We estimated the prevalence of use of antidepressants according to the adapted National Institute for Health and Care Excellence guidelines and used regression analysis to identify factors associated with possible over- and under-treatment.

RESULTS

In 41% (243/586) of assessments where antidepressants were indicated according to adapted National Institute for Health and Care Excellence guidelines, patients reported not taking them. Conversely in a third (557/1711) of assessments where guideline criteria were unlikely to be met, participants reported antidepressant use. Being female and chronic physical illness were associated with antidepressant use where guideline criteria were not met, but no factors were associated with not taking antidepressants where guideline criteria were met.

CONCLUSIONS

Much antidepressant treatment in general practice is for people with minimal or mild symptoms, while people with moderate or severe depressive symptoms may miss out. There is considerable scope for improving depression care through better allocation of antidepressant treatment.

Precision Medicine in Lifestyle Medicine: The Way of the Future?

Precision medicine has captured the imagination of the medical community with visions of therapies precisely targeted to the specific individual's genetic, biological, social, and environmental profile. However, in practice it has become synonymous with genomic medicine. As such its successes have been limited, with poor predictive or clinical value for the majority of people. It adds little to lifestyle medicine, other than in establishing why a healthy lifestyle is effective in combatting chronic disease. The challenge of lifestyle medicine remains getting people to actually adopt, sustain, and naturalize a healthy lifestyle, and this will require an approach that treats the patient as a person with individual needs and providing them with suitable types of support. The future of lifestyle medicine is holistic and person-centered rather than technological.

Antidepressive Mechanisms of Probiotics and Their Therapeutic Potential

The accumulating knowledge of the host-microbiota interplay gives rise to the microbiota-gut-brain (MGB) axis. The MGB axis depicts the interkingdom communication between the gut microbiota and the brain. This communication process involves the endocrine, immune and neurotransmitters systems. Dysfunction of these systems, along with the presence of gut dysbiosis, have been detected among clinically depressed patients. This implicates the involvement of a maladaptive MGB axis in the pathophysiology of depression. Depression refers to symptoms that characterize major depressive disorder (MDD), a mood disorder with a disease burden that rivals that of heart diseases. The use of probiotics to treat depression has gained attention in recent years, as evidenced by increasing numbers of animal and human studies that have supported the antidepressive efficacy of probiotics. Physiological changes observed in these studies allow for the elucidation of probiotics antidepressive mechanisms, which ultimately aim to restore proper functioning of the MGB axis. However, the understanding of mechanisms does not yet complete the endeavor in applying probiotics to treat MDD. Other challenges remain which include the heterogeneous nature of both the gut microbiota composition and depressive symptoms in the clinical setting. Nevertheless, probiotics offer some advantages over standard pharmaceutical antidepressants, in terms of residual symptoms, side effects and stigma involved. This review outlines antidepressive mechanisms of probiotics based on the currently available literature and discusses therapeutic potentials of probiotics for depression.

Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum

BACKGROUND

Protracted withdrawal syndrome (PWS) after stopping antidepressants (frequently also referred to as post-acute withdrawal syndrome or PAWS) has been described in a few case reports. However, a detailed quantitative analysis of specific symptom manifestations in antidepressant PWS is still lacking.

METHODS

We extracted patient narratives from a large English-language internet forum SurvivingAntidepressants.org, a peer support site concerned about withdrawal from antidepressants. PWS was ascertained based on diagnostic criteria proposed by Chouinard and Chouinard, specifically ⩾6 months of continuous antidepressant use, with emergence of new and/or more intense symptoms after discontinuation that last beyond the initial 6 weeks of acute withdrawal. We assessed medication history, outcome of PWS, and the prevalence of specific symptoms.

RESULTS

In total, n = 69 individual reports of protracted withdrawal were selected for analysis. At time of the subjects' most recent reports, duration of PWS ranged from 5 to 166 months, mean = 37 months, median = 26 months. Length of time on the antidepressant causing protracted withdrawal ranged from 6 to 278 months, mean = 96 months, and median = 79 months. Throughout the withdrawal experience, affective symptoms, mostly anxiety, depression, emerging suicidality and agitation, were reported by 81%. Somatic symptoms, mostly headache, fatigue, dizziness, brain zaps, visual changes, muscle aches, tremor, diarrhea, and nausea were reported by 75%. Sleep problems (44%) and cognitive impairments (32%) were mentioned less frequently. These broad symptom domains were largely uncorrelated.

CONCLUSION

PWS or PAWS from antidepressants can be severe and long-lasting, and its manifestations clinically heterogeneous. Long-term antidepressant exposure may cause multiple body system impairments. Although both somatic and affective symptoms are frequent, they are mostly unrelated in terms of occurrence. Proper recognition and detection of PWS thus requires a comprehensive assessment of medication history, duration of the withdrawal syndrome, and its various somatic, affective, sleep, and cognitive symptoms.

A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?

INTRODUCTION

The U.K.'s current National Institute for Health and Care Excellence and the American Psychiatric Association's depression guidelines state that withdrawal reactions from antidepressants are 'self-limiting' (i.e. typically resolving between 1 and 2weeks). This systematic review assesses that claim.

METHODS

A systematic literature review was undertaken to ascertain the incidence, severity and duration of antidepressant withdrawal reactions. We identified 24 relevant studies, with diverse methodologies and sample sizes.

RESULTS

Withdrawal incidence rates from 14 studies ranged from 27% to 86% with a weighted average of 56%. Four large studies of severity produced a weighted average of 46% of those experiencing antidepressant withdrawal effects endorsing the most extreme severity rating on offer. Seven of the ten very diverse studies providing data on duration contradict the U.K. and U.S.A. withdrawal guidelines in that they found that a significant proportion of people who experience withdrawal do so for more than two weeks, and that it is not uncommon for people to experience withdrawal for several months. The findings of the only four studies calculating mean duration were, for quite heterogeneous populations, 5days, 10days, 43days and 79weeks.

CONCLUSIONS

We recommend that U.K. and U.S.A. guidelines on antidepressant withdrawal be urgently updated as they are clearly at variance with the evidence on the incidence, severity and duration of antidepressant withdrawal, and are probably leading to the widespread misdiagnosing of withdrawal, the consequent lengthening of antidepressant use, much unnecessary antidepressant prescribing and higher rates of antidepressant prescriptions overall. We also recommend that prescribers fully inform patients about the possibility of withdrawal effects.

Rise in mortality involving poisoning by medicaments other than narcotics, including poisoning by psychotropic drugs in different age/racial groups in the US

BACKGROUND

Increase in mortality involving poisoning, particularly by narcotics, is known to have been one of the factors that affected life expectancy in the US during the last two decades, especially for white Americans and Native Americans. However, the contribution of medicaments other than narcotics to mortality in different racial/age groups is less studied.

METHODS

We regressed annual rates of mortality involving poisoning by medicaments but not narcotics/psychodysleptics (ICD-10 codes T36-39.xx or T41-50.8 but not T40.xx present as either underlying or contributing causes of death), as well as annual rates of mortality for certain subcategories of the above, including mortality involving poisoning by psychotropic drugs but not narcotics/psychodysleptics (ICD-10 codes T43.xx but not T40.xx present as either underlying or contributing causes of death) in different age/racial groups for both the 2000-2011 period and the 2011-2017 period against calendar year.

RESULTS

Annual numbers of deaths involving poisoning by medicaments but not narcotics/psychodysleptics grew from 4,332 between 2000-2001 to 11,401 between 2016-2017, with the growth in the rates of those deaths being higher for the 2011-2017 period compared to the 2000-2011 period. The largest increases in the rates of mortality involving poisoning by medicaments but not narcotics/psychodysleptics were in non-elderly Non-Hispanic Native Americans, followed by Non-Hispanic whites. Most of those increases came from increases in the rates of mortality involving poisoning by psychotropic medications; the latter rates grew for the period of 2015-2017 vs. 2000-2002 by factors ranging from 2.75 for ages 35-44y to 5.37 for ages 55-64y.

CONCLUSIONS

There were major increases in mortality involving poisoning by non-narcotic, particularly psychotropic medicaments, especially in non-elderly non-Hispanic whites and Native Americans. Our results support the need for a comprehensive evaluation of the effect of psychotropic medications on health-related outcomes, including mortality for causes other than poisoning, and the impact of medication misuse.

Preadmission use of antidepressants and risk of complications and death after colorectal cancer surgery: a nationwide population-based cohort study

AIM

Few studies have evaluated how preadmission use of antidepressants affects outcomes in colorectal cancer (CRC) patients after they have undergone surgery. Therefore, our aim is to examine whether preadmission use of antidepressants increased the risk of complications and death in patients who underwent CRC surgery.

METHOD

Using the Danish Colorectal Cancer Group Database we identified patients who underwent CRC surgery in Denmark from 2005 to 2012. We identified prescriptions for antidepressants redeemed within 1 year prior to surgery and categorized patients as current users (≤ 90 days), former users (91-365 days) and nonusers. All patients were followed from surgery to 30 days thereafter or to death. We calculated 30-day rates of complications, intensive care unit (ICU) admission and mortality and compared these between users and nonusers using logistic and Cox regression adjusting for potential confounders.

RESULTS

Of 27 374 patients, 8.9% were current users and 3.0% were former users. Antidepressant users were older and had more comorbidity but a similar cancer stage. Compared with nonusers, current users had a higher risk of postoperative reoperation [adjusted odds ratio (aORs) = 1.15 (95% CI 1.02-1.30)], medical complications [aORs = 1.41 (95% CI 1.25-1.60)] and increased ICU admission rate [adjusted hazard ratio (aHR) = 1.32 (95% CI 1.21-1.45)]. The 30-day mortality was 11.4% for current users, 9.1% for former users and 6.2% for nonusers [aHR = 1.34 (95% CI 1.17-1.53) for current vs nonusers].

CONCLUSION

Patients with preadmission use of antidepressants had a higher risk of complications and ICU admission, and higher 30-day mortality following CRC surgery than nonusers.

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

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

Antidepressant medication might increase the risk of self-harm injuries: findings in 17 OECD countries

Clinical trials suggest that antidepressants increase the risk of self-harm injuries (SHI). The aim was to investigate associations between antidepressants' use and the rate of change of SHI in 17 countries over the period 2000-16, with initial levels of SHI taken into account. The rate of change of SHI seems mainly (81%) determined by initial rates. The rate of SHI decreased in most countries. The decrease was slower in countries with a high level of antidepressants' use and in countries with an increase of depressive disorders. The study indicates that the use of antidepressants might increase the risk of SHI.

New Insights Into the Comorbidity of Coronary Heart Disease and Depression

Coronary heart disease (CHD) and depression are common disorders that markedly impair quality of life and impose a great financial burden on society. They are also frequently comorbid, exacerbating patient condition, and worsening prognosis. This comorbidity strongly suggests shared pathologic mechanisms. This review focuses on the incidence of depression in patients with CHD, deleterious effects of depression on CHD symptoms, and the potential mechanisms underlying comorbidity. In addition to the existing frequent mechanisms that are well known for decades, this review summarized interesting and original potential mechanisms to underlie the comorbidity, such as endocrine substances, gut microbiome, and microRNA. Finally, there are several treatment strategies for the comorbidity, involving drugs and psychotherapy, which may provide a theoretical basis for further basic research and clinical investigations on improved therapeutic interventions.

Effects of sulforaphane in the central nervous system

Sulforaphane (SFN) is an active component extracted from vegetables like cauliflower and broccoli. Activation of the nuclear factor (erythroid-derived 2)-like 2 (Nrf2) signaling is a common mechanism for the anti-oxidative and anti-inflammatory activity of some herb-derived compounds, such as icariin and berberine. However, due to its peculiar ability in Nrf2 activation, SFN is recognized as an activator of Nrf2 and recommended as a supplementation for prevention and/or treatment of disorders like neoplasm and heart failure. In the central nervous system (CNS), the prophylactic and/or therapeutic effects of SFN have been revealed in recent years. For example, it has been reported to prevent the progression of Alzheimer's disease, Parkinson's disease, cerebral ischemia, Huntington's disease, multiple sclerosis, epilepsy, and psychiatric disorders via promotion of neurogenesis or inhibition of oxidative stress and neuroinflammation. SFN is also implicated in reversing cognition, learning, and memory impairment in rodents induced by scopolamine, lipopolysaccharide, okadaic acid, and diabetes. In models of neurotoxicity, SFN has been shown to suppress neurotoxicity induced by a wide range of toxic factors, such as hydrogen peroxide, prion protein, hyperammonemia, and methamphetamine. To date, no consolidated source of knowledge about the pharmacological effects of SFN in the CNS has been presented in the literature. In this review, we summarize and discuss the pharmacological effects of SFN as well as their possible mechanisms in prevention and/or therapy of disorders afflicting the CNS, aiming to get a further insight into how SFN affects the pathophysiological process of CNS disorders.

Recent Developments in the Treatment of Depression

The cognitive and behavioral interventions can be as efficacious as antidepressant medications and more enduring, but some patients will be more likely to respond to one than the other. Recent work has focused on developing sophisticated selection algorithms using machine-learning approaches that answer the question, "What works best for whom?" Moreover, the vast majority of people suffering from depression reside in low- and middle-income countries where access to either psychotherapy or medications is virtually nonexistent. Great strides have been made in training nonspecialist providers (known as task sharing) to overcome this gap. Finally, recent work growing out of evolutionary psychology suggests that antidepressant medications may suppress symptoms at the expense of prolonging the underlying episode so as to increase the risk of relapse whenever someone tries to stop. We address each of these developments and their cumulative implications.

[Models of peer support in psychiatric care]

In the past decades, psychiatric care has changed from the traditional medical model to a more person-centered and recovery-focused approach. In this process, peer support workers are essential, because with their lived experience of crisis and recovery they are able to spread hope.This article gives an overview of the recent literature describing the current change model of peer support, reporting the evidence of peer support, as well as the current stage of implementation of peer support in different psychiatric contexts.An overview of the current state of research, selected by the authors, based on repeated systematic literature searches in peer support research projects, is given. Additionally, some examples of user involvement from the Hamburg EX-IN Curriculum, trialogs between sufferers, relatives and professionals, as well as the so-called psychosis seminars are described in more detail.Peer support has shown promising results in one-to-one and group settings, case management, crisis interventions, and the reduction of coercive measures.Although there are promising results of peer support in various clinical contexts, multiple challenges in the implementation of peer support are reported. They need to be overcome by the inclusion of all staff members in the change process of the system in order to further develop user-oriented and recovery-oriented psychiatric care.