Montgomery-Asberg severity gradations

Is suboptimal effort an issue? A systematic review on neuropsychological performance validity in major depressive disorder

BACKGROUND

In Major Depressive Disorder (MDD), emotion- and motivation related symptoms may affect effort during neuropsychological testing. Performance Validity Tests (PVT's) are therefore essential, but are rarely mentioned in research on cognitive functioning in MDD. We aimed to assess the proportion of MDD patients with demonstrated valid performance and determine cognitive functioning in patients with valid performance. This is the first systematic review on neuropsychological performance validity in MDD.

METHODS

Databases PubMed, PsycINFO, Embase, and Cochrane Library were searched for studies reporting on PVT results of adult MDD patients. We meta-analyzed the proportion of MDD patients with PVT scores indicative of valid performance.

RESULTS

Seven studies with a total of 409 MDD patients fulfilled inclusion criteria. Six studies reported the exact proportion of patients with PVT scores indicative of valid performance, which ranged from 60 to 100 % with a proportion estimate of 94 %. Four studies reported on cognitive functioning in MDD patients with valid performance. Two out of these studies found memory impairment in a minority of MDD patients and two out of these studies found no cognitive impairment.

LIMITATIONS

Small number of studies and small sample sizes.

CONCLUSIONS

A surprisingly small number of studies reported on PVT in MDD. About 94 % of MDD patients in studies using PVT's had valid neuropsychological test performance. Concessive information regarding cognitive functioning in MDD patients with valid performance was lacking. Neuropsychological performance validity should be taken into account since this may alter conclusions regarding cognitive functioning.

Managing depressive symptoms in people with mild cognitive impairment and mild dementia with a multicomponent psychotherapy intervention: a randomized controlled trial

OBJECTIVE

To evaluate the feasibility and effectiveness of the CORDIAL program, a psychosocial intervention consisting of cognitive behavioral therapy (CBT), cognitive rehabilitation, and reminiscence to manage depressive symptoms for people with mild cognitive impairment (MCI) or dementia.

DESIGN

We conducted a randomized controlled trial, based on a two-group (intervention and control), pre-/post-intervention design.

SETTING

Participants were recruited from five different old age psychiatry and memory clinics at outpatients' hospitals.

PARTICIPANTS

Hundred and ninety-eight people with MCI or early-stage dementia were included.

INTERVENTION

The intervention group (n = 100) received 11 individual weekly sessions of the CORDIAL program. This intervention includes elements from CBT, cognitive rehabilitation, and reminiscence therapy. The control group (n = 98) received treatment-as-usual.

MEASUREMENTS

We assessed Montgomery-Åsberg Depression Rating Scale (MADRS) (main outcome), Neuropsychiatric Inventory Questionnaire, and Quality of Life in Alzheimer's disease (secondary outcomes) over the course of 4 months and at a 10-month follow-up visit.

RESULTS

A linear mixed model demonstrated that the depressive symptoms assessed by MADRS were significantly more reduced in the intervention groups as compared to the control group (p < 0.001). The effect persisted for 6 months after the intervention. No significant differences between groups were found in neuropsychiatric symptoms or quality of life.

CONCLUSION

Our multicomponent intervention, which comprised 11 individual sessions of CBT, cognitive rehabilitation, and reminiscence therapy, reduced depressive symptoms in people with MCI and dementia.

Emotional and interpersonal mechanisms in community SSRI treatment of social anxiety disorder

BACKGROUND

Affective and interpersonal behavioural patterns characteristic of social anxiety disorder show improvement during treatment with serotonin agonists (e.g., selective serotonin reuptake inhibitors), commonly used in the treatment of social anxiety disorder. The present study sought to establish whether, during community psychopharmacological treatment of social anxiety disorder, changes in positive or negative affect and agreeable or quarrelsome behaviour mediate improvement in social anxiety symptom severity or follow from it.

METHODS

Adults diagnosed with social anxiety disorder (n = 48) recorded their interpersonal behaviour and affect naturalistically in an event-contingent recording procedure for 1-week periods before and during the first 4 months of treatment with paroxetine. Participants and treating psychiatrists assessed the severity of social anxiety symptoms monthly. A multivariate latent change score framework examined temporally lagged associations of change in affect and interpersonal behaviour with change in social anxiety symptom severity.

RESULTS

Elevated agreeable behaviour and positive affect predicted greater subsequent reduction in social anxiety symptom severity over the following month of treatment. Elevated negative affect, but not quarrelsome behaviour, predicted less subsequent reduction in symptom severity.

LIMITATIONS

Limitations included limited assessment of extreme behaviour (e.g., violence) that may have precluded examining the efficacy of paroxetine because of the lack of a placebo control group.

CONCLUSION

The present study suggests that interpersonal behaviour and affect may be putative mechanisms of action for serotonergic treatment of social anxiety disorder. Prosocial behaviour and positive affect increase during serotonergic treatment of social anxiety disorder. Specifically, modulating agreeable behaviour, positive affect and negative affect in individuals' daily lives may partially explain and refine clinical intervention.

Empirical evidence for definitions of episode, remission, recovery, relapse and recurrence in depression: a systematic review

AIMS.

For the past quarter of a century, Frank et al.'s (1991) consensus-based definitions of major depressive disorder (MDD) episode, remission, recovery, relapse and recurrence have been the paramount driving forces for consistency in MDD research as well as in clinical practice. This study aims to review the evidence for the empirical validation of Frank et al.'s proposed concept definitions and to discuss evidence-based modifications.

METHODS.

A literature search of Web of Science and PubMed from 1/1/1991 to 08/30/2017 identified all publications which referenced Frank et al.'s request for definition validation. Publications with data relevant for validation were included and checked for referencing other studies providing such data.

RESULTS.

A total of 56 studies involving 39 315 subjects were included, mainly presenting data to validate the severity and duration thresholds for defining remission and recovery. Most studies indicated that the severity threshold for defining remission should decrease. Additionally, specific duration thresholds to separate remission from recovery did not add any predictive value to the notion that increased remission duration alleviates the risk of reoccurrence of depressive symptoms. Only limited data were available to validate the severity and duration criteria for defining a depressive episode.

CONCLUSIONS.

Remission can best be defined as a less symptomatic state than previously assumed (Hamilton Rating Scale for Depression, 17-item version (HAMD-17) ⩽4 instead of ⩽7), without applying a duration criterion. Duration thresholds to separate remission from recovery are not meaningful. The minimal duration of depressive symptoms to define a depressive episode should be longer than 2 weeks, although further studies are required to recommend an exact duration threshold. These results are relevant for researchers and clinicians aiming to use evidence-based depression outcomes.

Affect, interpersonal behaviour and interpersonal perception during open-label, uncontrolled paroxetine treatment of people with social anxiety disorder: a pilot study

BACKGROUND

Laboratory-based research with community samples has suggested changes in affective, behavioural and cognitive processes as possible explanations for the effects of serotonergic medications. Examining the effects of serotonergic medications using an ecological momentary measure (such as event-contingent recording) in the daily lives of people with social anxiety disorder would contribute to establishing the effects of these medications on affect, behaviour and one form of cognition: perception of others’ behaviour.

METHODS

The present study assessed changes in affect, interpersonal behaviour and perception of others’ behaviour in adults with social anxiety disorder using ecological momentary assessment at baseline and over 4 months of a single-arm, uncontrolled, open-label trial of treatment with the selective serotonin reuptake inhibitor paroxetine.

RESULTS

Anxiety and concurrent depressive symptoms decreased. Participants also reported increased positive and decreased negative affect; increased agreeable and decreased quarrelsome behaviour; increased dominant and decreased submissive behaviour; and increased perception that others behaved agreeably toward them. Moreover, participants demonstrated reduced intraindividual variability in affect, interpersonal behaviour and perception of others’ behaviour.

LIMITATIONS

Limitations included the lack of a placebo group, the inability to identify the temporal order of changes and the restricted assessment of extreme behaviour.

CONCLUSION

The results of the present study demonstrate changes during pharmacotherapy in the manifestation of affect, interpersonal behaviour and interpersonal perception in the daily lives of people with social anxiety disorder. Given the importance of interpersonal processes to social anxiety disorder, these results may guide future research seeking to clarify mechanisms of action for serotonergic medications.

Free viewing of sad and happy faces in depression: A potential target for attention bias modification

BACKGROUND

Identification of reliable targets for therapeutic interventions is essential for developing evidence-based therapies. Attention biases toward negative-valenced information and lack of protective positive bias toward positive-valenced stimuli have been implicated in depression. However, extant research has typically used tasks with narrow stimuli arrays and unknown or poor psychometric properties. Here, we recorded eye-tracking data of depressed and non-depressed participants during a free viewing task to address these limitations.

METHODS

Patients with major depressive disorder (MDD; n = 20) and undergraduate students with high (n = 23) and low (n = 20) levels of depression freely viewed 60 different face-based matrices for six seconds each. Each matrix included eight sad and eight happy facial expressions. Gaze patterns on sad and happy areas of interest (AOIs) were explored. Internal consistency for the entire sample and one-week test-retest reliability in the student sub-sample were assessed.

RESULTS

Compared to undergraduates with low levels of depression, patients with MDD and students with high levels of depression dwelled significantly longer on sad faces. Results also showed a significantly longer dwell time on the happy AOI relative to the sad AOI only in the low depression group. The two depressed groups dwelled equally on the two AOIs. The task demonstrated high internal consistency and acceptable one-week test-retest reliability.

LIMITATIONS

Only sad and happy facial expressions were used. Relative small sample size.

CONCLUSION

Relative to non-depressed participants, depressed participants showed prolonged dwelling on sad faces and lack of bias toward happy faces. These biases present viable targets for gaze-contingent attention bias modification therapy.

Design considerations for handling dropouts in anti-depressant drug trials

BACKGROUND

In clinical trials, statistical analysis often requires certain assumptions about missing data for a valid statistical inference. If the dropout rate is high, a wrong assumption about the missing data may compromise the validity of statistical inferences.

PURPOSE

To mitigate the high dropout rates commonly observed in psychiatry clinical trials, we consider two design approaches for short-term controlled trials submitted in support of marketing applications for drug products for the major depressive disorder (MDD) indication: (1) shortening the trial duration and (2) treating time to treatment discontinuation as an alternative primary efficacy endpoint.

METHODS

Subject-level efficacy data from 45 trials for drugs approved for an MDD indication between 1997 and 2014 were collected. We analyzed change from baseline in Hamilton Depression Rating Scale (HAMD-17) total score using the mixed model repeated measures approach. We compared the least squares means and the 95% confidence intervals of the treatment effect among three different trial durations, 4, 6, and 8weeks. We considered two definitions of discontinuation: (i) all-cause discontinuation, (ii) discontinuation due to lack of efficacy. We compared the two-sided log-rank p-values with the p-values from the protocol-specified primary analysis.

CONCLUSIONS

Our findings suggest that MDD trials in the acute setting may be shortened to 6weeks provided that the treatment difference between drug and placebo on HAMD-17 total score reaches approximately 2units at Week 6. However, our exploratory analyses of available data do not support the use of time to treatment discontinuation as an alternative primary efficacy endpoint.

Alexithymia and perfectionism traits are associated with suicidal risk in patients with obsessive-compulsive disorder

BACKGROUND

There is limited evidence on suicidality and its associated factors in patients with obsessive-compulsive disorder (OCD). The present study investigated the potential contributing traits such as alexithymia and perfectionism and clinical risk factors including symptom dimensions associated with high suicidality in OCD patients.

METHODS

A total of 81 patients with OCD were included (mean age: 28.89 years, SD=7.95 years, 62% men). Suicidal risk was assessed using the Scale for Suicide Ideation and history taking. To assess alexithymia and perfectionism, the Toronto Alexithymia Scale-20 and the Measure of Constructs Underlying Perfectionism were applied. Clinical characteristics of OCD were assessed with the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Obsessive-Compulsive Scale, and the Montgomery-Asberg Depression Rating Scale. Among OCD patients, 37% had a history of previous suicidal attempt, and 56.8% had current suicidal ideation.

RESULTS

Those with lifetime suicide attempts scored significantly higher for alexithymia and ego-dystonic perfectionism than those without such history. In the binary logistic regression analysis, high score for alexithymia and the responsibility for harm, injury, or bad luck were significant determinants for lifetime suicide attempts. As for current suicide ideation, ego-dystonic perfectionism and the dimension of unacceptable thought were significant predictors of suicidal risk.

LIMITATIONS

The classification of suicidal risk and personality traits relied on self-report measures.

CONCLUSION

The present findings indicate that personality traits such as alexithymia and perfectionism may contribute to high suicidality in patients with OCD, and patients suffering with unacceptable thoughts need to be assessed more carefully for warning signs of suicide.

Non-24-hour sleep-wake syndrome improved by low-dose valproic acid: a case report

A woman was diagnosed with non-24-hour sleep-wake syndrome and depressive symptoms. Her depressive symptoms did not respond to standard doses of several antidepressants or mood stabilizers. Furthermore, her sleep-wake cycle remained non-entrained despite treatment with a melatonin-related drug, vitamin B12, and phototherapy. Ultimately, her sleep-wake rhythm was restored to a 24-hour pattern with a low dose of valproic acid, and her depressive symptoms tended to improve as a result of synchronization without antidepressants. Low-dose valproic acid appears to be one of the effective means of entraining circadian rhythms in patients with non-24-hour sleep-wake syndrome, which in turn likely improves associated depressive symptoms.

Hippocampal-DMN disconnectivity in MS is related to WM lesions and depression

The hippocampus is part of the default-mode network (DMN) and is functionally hit early in multiple sclerosis (MS). Hippocampal and DMN dysfunctions have been associated with depression, both in patients with MS and in major depressive disorders. We hypothesized that white matter lesions may contribute, through a disconnection mechanism, to hippocampal dysfunction. To test this, we assessed the relationship between hippocampal resting-state (RS) functional connectivity (FC) abnormalities with brain T2 lesion volumes and the presence and severity of depression. Structural and RS fMRI images were acquired from 69 patients with cognitively intact MS and 42 matched healthy controls (HC). Depression was quantified using the Montgomery-Asberg Depression Rating Scale. Seed-voxel hippocampal RS FC was assessed. SPM8 was used for between-group comparisons and correlation analysis between RS FC abnormalities with clinical and structural MRI variables. Compared to HC, patients with MS showed a significant atrophy of the whole brain and left hippocampus (P < 0.001), and a distributed pattern of decreased RS FC between the hippocampi and several cortical-subcortical regions, which were mostly located within the DMN. Reduced hippocampal RS FC with regions of the DMN was strongly correlated with higher T2 lesion volume, longer disease duration, and the severity of depression and disability. In patients with cognitively preserved MS, brain focal WM lesions are related to the functional integration of the hippocampus to other brain regions of the DMN, suggesting a disconnection syndrome. Such a disruption of hippocampal RS FC is likely to contribute to the occurrence of depression and to clinical disability.

Plasma brain-derived neurotrophic factor levels predict the clinical outcome of depression treatment in a naturalistic study

Remission is the primary goal of treatment for major depressive disorder (MDD). However, some patients do not respond to treatment. The main purpose of this study was to determine whether brain-derived neurotrophic factor (BDNF) levels are correlated with treatment outcomes. In a naturalistic study, we assessed whether plasma BDNF levels were correlated with clinical outcomes by measuring plasma BDNF in patients with depressive syndrome (MADRS score ≥18), and subsequently comparing levels between the subgroup of patients who underwent remission (MADRS score ≤8) and the subgroup who were refractory to treatment (non-responders). Patients with depressive syndrome who underwent remission had significantly higher plasma BDNF levels (p<0.001), regardless of age or sex. We also found a significant negative correlation between MADRS scores and plasma BDNF levels within this group (ρ = –0.287, p = 0.003). In contrast, non-responders had significantly lower plasma BDNF levels (p = 0.029). Interestingly, plasma BDNF levels in the non-responder group were significantly higher than those in the remission group in the initial stage of depressive syndrome (p = 0.002). Our results show that plasma BDNF levels are associated with clinical outcomes during the treatment of depression. We suggest that plasma BDNF could potentially serve as a prognostic biomarker for depression, predicting clinical outcome.

The generalizability of antidepressant efficacy trials to routine psychiatric out-patient practice

BACKGROUND

Generalizability of antidepressant efficacy trials (AETs) to daily practice is questioned because of their very stringent patient selection. This study aims to determine eligibility for AETs of out-patients suffering from major depression in a routine out-patient setting and investigates influence of eligibility on treatment outcome.

METHOD

Data collection (n = 1653) was performed through routine outcome monitoring by independent trained research nurses. The Mini-International Neuropsychiatric Interview Plus and the Dimensional Assessment of Personality Pathology, short Dutch version were used for diagnostic assessment and personality pathology screening. The Montgomery-Asberg Depression Rating Scale (MADRS) was used for assessment of baseline severity and treatment outcome. Eligibility was assessed by stepwise application of commonly used exclusion criteria. Influence of eligibility on treatment outcome was investigated in a subsample of the 1653 patients who had at least one follow-up assessment (n = 626). Eligible and non-eligible patients were compared on proportion of response (50% reduction) and remission on MADRS (MADRS ≤ 10).

RESULTS

Altogether, 17-25% of the patients were eligible for AETs. The most common reasons for exclusion would be 'not meeting minimum baseline severity' and 'presence of co-morbid Axis I disorder'. Eligible and non-eligible patients did not differ in treatment outcome. Only 'meeting the minimum baseline severity' is associated with remission.

CONCLUSIONS

The majority of 'real life' out-patients are not eligible for AETs. However, the influence of eligibility on treatment outcome seems to be small. This suggests that stringent patient selection by eligibility criteria is not the major reason for lack of generalizability of AETs. Exclusion of less severely depressed patients from the analyses resulted in better treatment outcome. Milder depression is highly prevalent in daily practice and more research into treatment effectiveness in milder depression is warranted.

Effects of asenapine on depressive symptoms in patients with bipolar I disorder experiencing acute manic or mixed episodes: a post hoc analysis of two 3-week clinical trials

BACKGROUND

Asenapine demonstrated superiority over placebo for mania in bipolar I disorder patients experiencing acute current manic or mixed episodes in 2 randomized, placebo-and olanzapine-controlled trials. We report the results of exploratory pooled post hoc analyses from these trials evaluating asenapine's effects on depressive symptoms in patients from these trials with significant baseline depressive symptoms.

METHODS

In the original trials (A7501004 [NCT00159744], A7501005 [NCT00159796]), 977 patients were randomized to flexible-dose sublingual asenapine (10 mg twice daily on day 1; 5 or 10 mg twice daily thereafter), placebo, or oral olanzapine 5-20 mg once daily for 3 weeks. Three populations were defined using baseline depressive symptoms: (1) Montgomery-Asberg Depression Rating Scale (MADRS) total score ≥20 (n = 132); (2) Clinical Global Impression for Bipolar Disorder-Depression (CGI-BP-D) scale severity score ≥4 (n = 170); (3) diagnosis of mixed episodes (n = 302) by investigative site screening. For each population, asenapine and olanzapine were independently compared with placebo using least squares mean change from baseline on depressive symptom measures.

RESULTS

Decreases in MADRS total score were statistically greater with asenapine versus placebo at days 7 and 21 in all populations; differences between olanzapine and placebo were not significant. Decreases in CGI-BP-D score were significantly greater with asenapine versus placebo at day 7 in all categories and day 21 in population 1; CGI-BP-D score reductions were significantly greater with olanzapine versus placebo at day 21 in population 1 and day 7 in populations 2 and 3.

CONCLUSIONS

These post hoc analyses show that asenapine reduced depressive symptoms in bipolar I disorder patients experiencing acute manic or mixed episodes with clinically relevant depressive symptoms at baseline; olanzapine results appeared to be less consistent. Controlled studies of asenapine in patients with acute bipolar depression are necessary to confirm the generalizability of these findings.

Contributors to neuropsychological impairment in HIV-infected and HIV-uninfected opiate-dependent patients

Neuropsychological (NP) impairment is multiply determined among HIV-infected and HIV-uninfected individuals who are also dually diagnosed with depression and who use illicit substances. The purpose of the present study was to assess the impact of HIV status, depression, and problematic substance use on NP performance. A total of 160 opiate-dependent outpatients undergoing methadone maintenance (80 HIV-infected, 80 HIV-uninfected) completed diagnostic and NP evaluations. Raw scores from individual NP tests were converted to Z scores relative to standard norms and were averaged to form a composite score. HIV-infected participants had significantly lower overall NP performance--as well as lower performance on tests of attention, motor speed, and verbal memory--than HIV-uninfected participants. In multiple regression analyses considering the role of depression and substance use, only HIV status emerged as a significant predictor of NP impairment. These findings confirm NP impairment in HIV-infected substance abusing patients independent of comorbid depression and severity of substance use.

Relationships between auditory event-related potentials and mood state, medication, and comorbid psychiatric illness in patients with bipolar disorder

BACKGROUND

Patients with bipolar disorder (BD) exhibit aberrations in auditory event-related potentials (ERPs), although the relationships between these measures and mood state at testing, comorbid psychiatric illness, presence of psychotic features, and medication usage are unclear. The purpose of this study was to investigate the relationships between these factors and auditory ERP measures in BD patients.

METHODS

An auditory 'oddball' discrimination task was used to elicit ERPs from 69 patients with type I BD and 52 healthy controls. Patients were placed into subgroups based upon their mood state at testing (euthymic or symptomatic), and ANOVA was used to compare amplitude and peak latency measures from the N100, P200, N200, and P300 ERP components across subgroups. Multiple regression was used to investigate relationships between ERP measures and comorbid psychiatric diagnosis, history of psychotic features, and medication status.

RESULTS

Relative to healthy control participants, euthymic and symptomatic BD patients exhibited reduced P300 and P200 amplitude, but ERP measures did not differ among BD patients on the basis of mood status. A history of a comorbid anxiety disorder was associated with reduced N200 peak latency, but prolonged P300 peak latency among BD patients. No other relationships between clinical variables and ERP measures were significant.

CONCLUSIONS

The results suggest that disrupted auditory attention may be observed in BD patients regardless of their mood state at testing, medication status, or history of psychosis. These results extend previous findings, and provide further evidence for aberrations in the P300 ERP as an endophenotype for BD.

Aripiprazole augmentation in major depressive disorder: a double-blind, placebo-controlled study in patients with inadequate response to antidepressants

INTRODUCTION

Effective management of major depressive disorder (MDD) continues to be a challenging task for psychiatrists and primary care physicians. This trial evaluated the efficacy and safety of adjunctive aripiprazole versus antidepressant monotherapy in patients with MDD and independently replicated the positive findings of two similar trials.

METHODS

Patients (N=1,147) with MDD experiencing a major depressive episode and a history of inadequate response to antidepressant monotherapy were enrolled (week 0); 827 received single-blind adjunctive placebo plus open-label antidepressant (escitalopram, fluoxetine, paroxetine controlled release, sertraline, or venlafaxine extended release) for 8 weeks to confirm inadequate response to antidepressants; 349 patients with inadequate response were randomized (1:1) to double-blind, adjunctive placebo (n=172) or adjunctive aripiprazole (n=177; 2-20 mg/day). Primary outcome was the mean change in Montgomery-Asberg Depression Rating Scale (MADRS) Total score from baseline (week 8) to endpoint (week 14).

RESULTS

Clinically significant improvements in depressive symptoms as assessed by decreases in the MADRS Total score were greater with adjunctive aripiprazole (-10.1) than placebo (-6.4; P<.001). Remission rates were greater for adjunctive aripiprazole than for adjunctive placebo (week 14, 36.8% vs 18.9%; P<.001). Completion rates with adjunctive aripiprazole and placebo were high (83% vs. 87%) and discontinuations due to adverse events were low (6.2% vs 1.7%).

CONCLUSION

For some patients with MDD who do not obtain adequate symptom relief with antidepressant monotherapy, adjunctive therapies can significantly improve depressive symptoms. As reported, adjunctive aripiprazole was associated with a two-fold higher remission rate than adjunctive placebo. This, and previous studies, have shown that discontinuations due to adverse events were low and completion rates were high, and has indicated that both antidepressant and aripiprazole in combination were relatively well-tolerated and safe. This is the third consecutive clinical trial, in the absence of a failed trial, to demonstrate that aripiprazole augmentation to antidepressants is an efficacious and well-tolerated treatment for patients with MDD who do not respond adequately to standard antidepressant monotherapy (ClinicalTrials.gov study NCT00105196).

Cost-effectiveness of interpersonal psychotherapy for elderly primary care patients with major depression

Objectives:Major depression is common in elderly patients. Interpersonal psychotherapy (IPT) is a potentially effective treatment for depressed elderly patients. The objective of this study was to evaluate the cost-effectiveness of IPT delivered by mental health workers in primary care practices, for depressed patients 55 years of age and older identified by screening, in comparison with care as usual (CAU).

Methods:We conducted a full economic evaluation alongside a randomized controlled trial comparing IPT with CAU. Outcome measures were depressive symptoms, presence of major depression, and quality of life. Resource use was measured from a societal perspective over a 12-month period by cost diaries. Multiple imputation and bootstrapping were used to analyze the data.

Results:At 6 and 12 months, the differences in clinical outcomes between IPT and CAU were small and nonsignificant. Total costs at 12 months were €5,753 in the IPT group and €4,984 in the CAU group (mean difference, €769; 95 percent confidence interval, −2,459 – 3,433). Cost-effectiveness planes indicated that there was much uncertainty around the cost-effectiveness ratios.

Conclusions:Based on these results, provision of IPT in primary care to elderly depressed patients was not cost-effective in comparison to CAU. Future research should focus on improvement of patient selection and treatments that have more robust effects in the acute and maintenance phase of treatment.

The effect of depression, anxiety and early life trauma on the cortisol awakening response during pregnancy: preliminary results

The purpose of this study was to examine the effects of maternal depression and anxiety on the cortisol awakening response (CAR), a marker of the hypothalamic-pituitary-adrenal (HPA) axis function, during pregnancy. Sixty-six pregnant women were studied between 25 and 33 weeks of gestation and were identified as either Depressed (n=33) or healthy, Control (n=33), based on depression scores and lifetime psychiatric history. Saliva samples were collected (passive drool) upon awakening and at +30 and +60 min thereafter. The CAR was not significantly different between women who were depressed during pregnancy compared to healthy control women. However, women taking antidepressant (AD) medication showed an attenuated CAR (time x AD use interaction, p=0.06). Childhood maltreatment (as measured with the Childhood Trauma Questionnaire) was associated with a lower baseline cortisol concentration explaining 12% of the variance, controlling for wake-up time and AD use. There is a complex interplay of factors involved in the HPA axis regulation of vulnerable women during pregnancy, including depression, anxiety, early life stress and psychotropic medication use, which remain unclear. The CAR may provide important information about the maternal HPA axis during pregnancy and warrants further investigation in larger cohorts.

Cost-effectiveness of a disease management program for major depression in elderly primary care patients

BACKGROUND

Major depression is common in older adults and is associated with increased health care costs. Depression often remains unrecognized in older adults, especially in primary care.

OBJECTIVE

To evaluate the cost-effectiveness of a disease management program for major depression in elderly primary care patients compared with usual care.

DESIGN

Economic evaluation alongside a cluster randomized-controlled trial.

PARTICIPANTS

Consecutive patients of 55 years and older were screened for depression using the Geriatric Depression Scale and the PRIME-MD was used for diagnosis.

INTERVENTIONS

General practitioners in the intervention group received training on how to implement the disease management program consisting of screening, patient education, drug therapy with paroxetine, and supportive contacts. General practitioners in the usual care group were blind to the screening results. Treatment in this group was not restricted in any way.

MEASUREMENTS

Severity of depression, recovery from depression, and quality of life. Resource use measured over a 12-month period using interviews and valued using standard costs.

RESULTS

Differences in clinical outcomes between the intervention and usual care group were small and statistically insignificant. Total costs were 2,123 dollars in the intervention and 2,259 dollars in the usual care group (mean difference -136 dollars, 95% confidence interval: -1,194 dollars; 1,110 dollars). Cost-effectiveness planes indicated that there were no statistically significant differences in cost-effectiveness between the 2 groups.

CONCLUSIONS

This disease management program for major depression in elderly primary care patients had no statistically significant relationship with clinical outcomes, costs, and cost-effectiveness. Therefore, based on these results, continuing usual care is recommended.

Neocortical volume decrease in relapsing-remitting multiple sclerosis with mild cognitive impairment

The aim of the study was to assess neocortical changes and their relevance to cognitive impairment in early relapsing-remitting multiple sclerosis (RRMS). Conventional magnetic resonance was acquired in 41 RRMS patients and 16 demographically matched normal controls (NC). An automated analysis tool was used to obtain measures of cortical brain volumes normalized for head size. Neuropsychological performance of MS patients was assessed through the Rao's Brief Repeatable Battery. We identified 18 cognitively preserved (MS-cp) and 23 cognitively impaired (MS-ci) MS patients. Values of normalized cortical volumes (NCV) in the whole MS sample were lower than those in the NC group (p=0.01). MS-ci patients showed NCV values lower (p=0.02) than did both MS-cp patients and NC. Moreover, we found a positive correlation between NCV values and measures of verbal memory (r=0.51, p=0.02), verbal fluency (r=0.51, p=0.01) and attention/concentration (r=0.65, p<0.001) in MS-ci patients. Furthermore, NCV values were significantly decreased in patients who scored lower on a greater number of tests (r=-0.58, p<0.01) in the MS-ci group. Only MS-ci patients had cortical atrophy significantly correlated with a poorer neuropsychological performance. Grey matter pathology may contribute to the development of cognitive impairment in MS from the earliest stages of the disease.

Derivation of a definition of remission on the Montgomery-Asberg depression rating scale corresponding to the definition of remission on the Hamilton rating scale for depression

During the past decade the Montgomery-Asberg Depression Rating Scale (MADRS) has been used with increasing frequency to measure outcome in antidepressant efficacy trials (AETs). In characterizing treatment outcome in AETs it is common to define treatment remission as a score below a predetermined cutoff score on the scale. Various cutoffs have been used to define remission on the MADRS. The goal of the present paper is to determine the cutoff on the MADRS that most closely corresponds to the cutoff most frequently used on the Hamilton Rating Scale for Depression to define remission. Three hundred and three psychiatric outpatients who were being treated for a DSM-IV major depressive episode were rated on the HRSD and the MADRS. A linear regression equation was computed to estimate MADRS scores from HRSD scores. After deriving the regression equation, we computed the MADRS score corresponding to an HRSD score of 7. We also examined the sensitivity, specificity and overall classification rate of the MADRS for identifying remission on the HRSD. Based on the equation from a linear regression analysis for the entire sample, a MADRS score of </=11 would correspond to a score of </=7 on the HRSD. We repeated the analysis after excluding the more severely depressed patients who currently met criteria for MDD, and based on the equation from this regression analysis a MADRS score of </=10 would correspond to a score of </=7 on the HRSD. In a complementary analysis, we examined the sensitivity, specificity and overall classification rate of the MADRS at different cutoff points for identifying remission, and found that a cutoff of </=10 maximized the level of agreement with the HRSD definition of remission. In conclusion, the regression equation relating HRSD and MADRS scores is dependent, in part, on the range and severity of scores in the sample. To facilitate comparisons of studies using the HRSD and MADRS our results suggest that a cutoff of 10 on the MADRS is equivalent to the HRSD cutoff of 7.

Meta-Analysis of Placebo Rates in Major Depressive Disorder Trials

BACKGROUND

Placebo effects in major depressive disorder (MDD) have received much interest in the medical literature. However, few quantitative analyses have been done in homogeneous populations.

OBJECTIVE

To determine efficacy rates for placebo in patients with MDD; to quantify the correlation between efficacy and publication year, as well as between placebo and drug response rates.

DESIGN

Searching MEDLINE (1966-December 2000), EMBASE (1998-February 2001), HealthSTAR (1975-December 2000), and Cochrane (1980-December 2000) databases, randomized, placebo-controlled trials were retrieved including patients with MDD as defined by Diagnostic and Statistical Manual of Mental Disorders, 3rd and 4th editions criteria, Hamilton Rating Scale for Depression score >/=18 or Montgomery-Asberg Depression Rating Scale score >/=16, reporting successes as 50% decreases in scores after 6-8 weeks of treatment. Response rates were summarized using a random effects meta-analysis for per protocol (PP) and intent-to-treat (ITT) results.

RESULTS

We included 24 of 134 potential studies examining 4459 patients, 1786 on placebo and 2673 on an antidepressant. Placebo response rates were 45.5% (PP) and 26.9% (ITT). Correlations were significant between year and rates (PP rho 0.448, p = 0.042; ITT rho 0.557; p = 0.006), but not for active drugs. Placebo and drug rates were correlated (PP r 0.397, p = 0.020; ITT r 0.539; p = 0.002).

CONCLUSIONS

These placebo rates confirm those reported previously, but were from a homogeneous population. Although statistically significant, the correlation between drug and placebo rates was lower than others reported. During the study period, placebo rates increased linearly; active drugs did not. Correlations between placebo and drug response rates reflected moderate to strong effect sizes. We suggest that current methodology has been unsuccessful in achieving unbiased double-blind conditions not influenced by extra-trial factors, including time.

Carbamazepine augmentation in depressive patients non-responding to citalopram: a pharmacokinetic and clinical pilot study

Citalopram is a chiral antidepressant drug. Its eutomer, S-citalopram (escitalopram), has recently been introduced as an antidepressant. In an open pilot study, four outpatients and two inpatients with a major depressive episode (ICD-10), and who were nonresponders to a 4-week pretreatment with 40-60 mg/day citalopram, were comedicated for another 4-week period with carbamazepine (200-400 mg/day). Some of the patients suffered also from comorbidities: Phobic anxiety disorder with panic attacks (n=2), generalised anxiety disorder, alcohol abuse, dependent personality disorder, hypertension (n=1). After a 4-week augmentation therapy with carbamazepine, a significant (P<0.03) decrease of the plasma concentrations of S-citalopram and R-citalopram, by 27 and 31%, respectively, was observed. Apparently, the probable induction of CYP3A4 by carbamazepine results in a nonstereoselective increase in N-demethylation of citalopram. Moreover, there was a significant (P<0.03) decrease of the ratio S/R-citalopram propionic acid derivative, the formation of it being partly regulated by MAO-A and MAO-B. Already, within 1 week after addition of carbamazepine, there was a slight but significant (P<0.03) decrease of the MADRS depression scores, from 27.0+/-7.7 (mean+/-S.D.) to 23.3+/-6.6, and the final score on day 56 was 18.8+/-10.9. The treatment was generally well tolerated. There was no evidence of occurrence of a serotonin syndrome. After augmentation with carbamazepine, treatment related adverse events were: Nausea in one case, diarrhea in one case, and rash in two cases. In conclusion, the results of this pilot study suggest that carbamazepine augmentation of a citalopram treatment in previous nonresponders to citalopram may be clinically useful, but that in addition carbamazepine can lead to a decrease of the plasma concentrations of the active enantiomer escitalopram.

Moderate and severe depression. Gradations for the Montgomery-Asberg Depression Rating Scale

BACKGROUND

Despite its importance, no distinction between moderate and severe depression using the Montgomery-Asberg Depression Rating Scale (MADRS) based on a direct comparison with the Hamilton Depression Rating Scale (HAMD-17) is available.

METHODS

HAMD-17 and MADRS ratings from N=40 at least moderately depressed inpatients with major depression (DSM-III-R) were analyzed. Linear and non-parametric correlations were computed and a MADRS cut-off score for severe depression using an HAMD-17 score of at least 28 points as reference was estimated.

RESULTS

HAMD-17 and MADRS mean scores were 24.6+/-4.3 and 32.6+/-5.0 points, respectively. Linear correlation of both scores was r=0.70 (P<0.0005). A MADRS cut-off score of at least 35 points was estimated to separate 'moderate' from 'severe' depression corresponding to a HAMD-17 cut-off of 28 points with sufficient sensitivity and specificity.

LIMITATIONS

The sample size was limited and no observer ratings directly assessing the severity of depression were used.

CONCLUSIONS

The preliminary findings are in line with previous findings and suggest a cut-off score of 35 points to separate moderate from severe depression with the MADRS accepting an HAMD-17 score of >/=28 point as reference. Further studies on this issue are warranted.