Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Ketamine for Major Depressive Disorder

Major Depressive Disorder (MDD) is a leading cause of disability worldwide. Conventional antidepressant treatment is characterised by a significant time to onset of therapeutic action (approximately 2 weeks) and fails to achieve a stable remission of symptoms in one-third of subjects with MDD. In the last 20 years the discovery of antidepressant effects of the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine as a rapid acting (within hours) and sustained (up to 7 days) antidepressant has represented a major paradigm shift in the field.The present chapter reviews the pharmacology, safety, and efficacy of ketamine as a novel therapeutic agent for MDD and specifically for subjects who did not respond to conventional antidepressant (treatment resistant depression). The impact of ketamine on suicidal ideation, the availability of brain biomarkers of ketamine treatment response and the association of ketamine and psychotherapy are considered.

Modern Methods of Diagnostics and Treatment of Neurodegenerative Diseases and Depression

This paper discusses the promising areas of research into machine learning applications for the prevention and correction of neurodegenerative and depressive disorders. These two groups of disorders are among the leading causes of decline in the quality of life in the world when estimated using disability-adjusted years. Despite decades of research, the development of new approaches for the assessment (especially pre-clinical) and correction of neurodegenerative diseases and depressive disorders remains among the priority areas of research in neurophysiology, psychology, genetics, and interdisciplinary medicine. Contemporary machine learning technologies and medical data infrastructure create new research opportunities. However, reaching a consensus on the application of new machine learning methods and their integration with the existing standards of care and assessment is still a challenge to overcome before the innovations could be widely introduced to clinics. The research on the development of clinical predictions and classification algorithms contributes towards creating a unified approach to the use of growing clinical data. This unified approach should integrate the requirements of medical professionals, researchers, and governmental regulators. In the current paper, the current state of research into neurodegenerative and depressive disorders is presented.

Prenatal Venlafaxine Exposure-Induced Neurocytoarchitectural and Neuroapoptotic Degeneration in Striatum and Hippocampus of Developing Fetal Brain, Manifesting Long-term Neurocognitive Impairments in Rat Offspring

Depression is a leading cause of disability which at its worst leads to suicide. Its treatment relies on psychotherapy in combination with certain antidepressants (AD_(s)) from various classes such as tricyclics, selective serotonin reuptake inhibitors, or serotonin and norepinephrine reuptake inhibitors (SNRIs). Among SNRIs, venlafaxine (VEN) is one such most commonly prescribed AD which is recently reported to be in the top 50 most prescribed drugs in the USA. Depression during pregnancy is a common condition, where prescribing an AD becomes necessary as untreated depression during pregnancy has its own complications for both mother and the child. This, probably, is why an incredible rise has been reported in prescribing ADs like VEN to pregnant women in the recent past, despite some studies, including the one from our own group, having reported the in-utero VEN-induced apoptotic neurodegeneration in the fetal neocortex and the consequent neurobehavioral anomalies in adulthood. However, there still exists a lack of insight into the effects of intrauterine exposures of VEN on other fetal brain regions like the hippocampus (HPC) and striatum (STR) and the consequent effects on their cognitive and emotional wellbeing in later life. Hence, this study has been conducted where pregnant Charles-Foster (CF) rats were oral gavaged with VEN (25, 40, and 50 mg/kg bw) from gestation day (GD) 05-19. On GD-19, half of the control and treated dams were euthanized to collect their fetuses. Fetal brains were dissected and processed for reactive oxygen species (ROS) estimation neurohistopathology and confocal microscopic studies. The remaining dams were allowed to deliver naturally, and litters were reared for up to 8 weeks then tested for their cognitive abilities by the Morris water maze test and for their emotionality by the Forced swimming test. Our results showed substantial neurocytoarchitectural deficits in both HPC and STR, along with enhanced ROS levels and apoptotic neurodegenerations. Furthermore, VEN-treated young rat offsprings displayed cognitive impairments and depressive behavior as the long-lasting impact of VEN in a dose-dependent manner. So it may be inferred that prenatal VEN-induced oxidative stress causes apoptotic neurodegeneration leading to neuronal loss in HPC and STR which consequently affects the development of the said brain areas resulting in impaired cognitive and emotional abilities of young adult offsprings. Therefore, extrapolating these findings in animal models, caution may be taken before prescribing VEN to pregnant women, especially during the sensitive phase of pregnancy.

Toward Synergies of Ketamine and Psychotherapy

Ketamine is a dissociative drug that has been used medically since the 1970s primarily as an anesthetic agent but also for various psychiatric applications. Anecdotal reports and clinical research suggest substantial potential for ketamine as a treatment in conjunction with psychological interventions. Here, we review historical and modern approaches to the use of ketamine with psychotherapy, discuss the clinical relevance of ketamine’s acute psychoactive effects, propose a unique model for using esketamine (one isomeric form of ketamine) with Acceptance and Commitment Therapy (ACT), and suggest considerations for moving medication-assisted psychotherapy forward as a field.

Meta-Analysis of Positive Psychology Interventions on the Treatment of Depression

This meta-analysis examined the efficacy of positive psychology interventions (PPIs) in treating depression in 11 articles. PubMed, Web of Science, and Clinical Key were used to identify papers published from 2010 to 2020 that utilized PPIs. Key terms were “positive psychology” and “treatment of depression.” Studies on adults with (a) depressive symptoms or (b) diagnosed clinical depression were included. A random-effects model was used to compare PPIs and control groups on post- vs. pre-intervention differences in depression scores. Data analysis examined Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), and Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) scores. Findings show PPIs are effective in treating depressive symptoms, with significant improvements in depression scores when compared to control groups in all but one study. This was true for both post- vs. pre-intervention (pooled Cohen’s d = −0.44 (−0.77, −0.11)) and follow-up- vs. pre-intervention analyses (pooled Cohen’s d = −0.46 (−1.02, 0.09)). PPIs can improve the accessibility and affordability of depression treatments.

A Systematic Review and Individual Patient Data Network Analysis of the Residual Symptom Structure Following Cognitive-Behavioral Therapy and Escitalopram, Mirtazapine and Venlafaxine for Depression

OBJECTIVE

Consistent evidence suggests residual depressive symptomology are the strongest predictors of depression relapse following cognitive-behavioral therapy (CBT) and antidepressant medications (ADM's). Psychometric network models help detecting and understanding central symptoms that remain post-treatment, along with their complex co-occurrences. However, individual psychometric network studies show inconsistent findings. This systematic review and IPD network analysis aimed to estimate and compare the symptom network structures of residual depressive symptoms following CBT, ADM's, and their combination.

METHODS

PsycINFO, PsycArticles, and PubMed were systematically searched through October 2020 for studies that have assessed individuals with major depression at post-treatment receiving either CBT and/or ADM's (venlafaxine, escitalopram, mirtazapine). IPD was requested from eligible samples to estimate and compare residual symptom psychometric network models post-CBT and post-ADM's.

RESULTS

In total, 25 from 663 eligible samples, including 1,389 patients qualified for the IPD. Depressed mood and anhedonia were consistently central residual symptoms post-CBT and post-ADM's. For CBT, fatigue-related and anxiety symptoms were also central post-treatment. A significant difference in network structure across treatments (CBT vs. ADM) was observed for samples measuring depression severity using the MADRS. Specifically, stronger symptom occurrences were present amongst lassitude-suicide post-CBT (vs. ADM's) and amongst lassitude-inability to feel post-ADM's (vs. CBT). No significant difference in global strength was observed across treatments.

CONCLUSIONS

Core major depression symptoms remain central across treatments, strategies to target these symptoms should be considered. Anxiety and fatigue related complaints also remain central post-CBT. Efforts must be made amongst researchers, institutions, and journals to permit sharing of IPD.Systematic Review Registration: A protocol was prospectively registered on PROSPERO (CRD42020141663; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=141663).

Suicidal ideation and other persisting symptoms after CBT or antidepressant medication treatment for major depressive disorder

BACKGROUND

Persisting symptoms after treatment for major depressive disorder (MDD) contribute to ongoing impairment and relapse risk. Whether cognitive behavior therapy (CBT) or antidepressant medications result in different profiles of residual symptoms after treatment is largely unknown.

METHODS

Three hundred fifteen adults with MDD randomized to treatment with either CBT or antidepressant medication in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study were analyzed for the frequency of residual symptoms using the Montgomery Asberg Depression Rating Scale (MADRS) item scores at the end of the 12-week treatment period. Separate comparisons were made for treatment responders and non-responders.

RESULTS

Among treatment completers (n = 250) who responded to CBT or antidepressant medication, there were no significant differences in the persistence of residual MADRS symptoms. However, non-responders treated with medication were significantly less likely to endorse suicidal ideation (SI) at week 12 compared with those treated with CBT (non-responders to medication: 0/54, 0%, non-responders to CBT: 8/30, 26.7%; p = .001). Among patients who terminated the trial early (n = 65), residual MADRS item scores did not significantly differ between the CBT- and medication-treated groups.

CONCLUSIONS

Depressed adults who respond to CBT or antidepressant medication have similar residual symptom profiles. Antidepressant medications reduce SI, even among patients for whom the medication provides little overall benefit.

Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression

OBJECTIVE

Adults with major depressive disorder frequently do not achieve remission with an initial treatment. Addition of psychotherapy for patients who do not achieve remission with antidepressant medication alone can target residual symptoms and protect against recurrence, but the utility of adding antidepressant medication after nonremission with cognitive-behavioral therapy (CBT) has received little study. The authors aimed to evaluate the acute and long-term outcomes resulting from both sequences of combination treatments.

METHODS

Previously untreated adults with major depression who were randomly assigned to receive escitalopram, duloxetine, or CBT monotherapy and completed 12 weeks of treatment without achieving remission entered an additional 12 weeks of combination treatment. For patients who did not achieve remission with CBT, escitalopram was added (CBT plus medication group) to their treatment, and for those who did not achieve remission with an antidepressant, CBT was added (medication plus CBT group) to their treatment. Patients who responded to the combination treatment entered an 18-month follow-up phase to assess risk of recurrence.

RESULTS

A total of 112 patients who did not achieve remission with a monotherapy entered combination treatment (41 who responded to monotherapy but did not achieve remission and 71 who did not respond to monotherapy). Overall, remission rates after subsequent combination therapy were significantly higher among patients who responded to monotherapy but did not achieve remission (61%) than among patients who did not respond to monotherapy (41%). Among patients who responded to monotherapy but did not achieve remission, the remission rate in the CBT plus medication group (89%) was higher than in the medication plus CBT group (53%). However, among patients whose depression did not respond to monotherapy, rates of response and remission were similar between the treatment arms. Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups.

CONCLUSIONS

The order in which CBT and antidepressant medication were sequentially combined did not appear to affect outcomes. Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality.

Reported maladaptive decision-making in unipolar and bipolar depression and its change with treatment

Mood disorder patients frequently experience difficulty making decisions and may make sub-optimal decisions with adverse life consequences. However, patients' styles for decision-making when ill and after treatment have received little study to date. We assessed healthy controls (HC, n = 69) and patients with major depressive disorder (MDD, n = 61) or bipolar disorder (BP, n = 26) in a current major depressive episode using the Melbourne Decision-making Questionnaire. A subset of participants was re-evaluated after completing six weeks of pharmacotherapy. HC demonstrated significantly greater use of the healthy vigilance style, and significantly lower use of maladaptive decision-making styles, than the MDD and depressed BP patients. After six weeks of treatment, neither the MDD nor BP patients reported meaningful improvements in the vigilance style of decision-making, but scores on most maladaptive decision-making styles declined. BP patients who remitted reported significantly lower buckpassing and procrastination scores than healthy controls. Among MDD patients, however, the maladaptive passive buckpassing style of decision-making did not significantly diminish. For MDD patients, reported decision-making styles may remain impaired even after achieving remission. Among BP patients, low levels of adaptive vigilance decision-making may be a trait component of the illness, whereas for MDD patients, reported maladaptive passive decision-making styles are persistent.

Toxicologic Emergencies in Patients with Mental Illness: When Medications Are No Longer Your Friends

Patients with psychiatric disorders are at risk for toxicologic emergencies. Psychotropic medications have numerous effects on the neurologic, cardiac, and other organ systems and interact with other medications, potentially leading to further side effects. It is important to become familiar with accepted psychiatric practice guidelines, common toxidromes, medical sequelae associated with prescribed medications, and the specific workup and treatment of overdoses of frequently prescribed psychotropics.