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Hanna-Jairala I, Drossman DA. Central Neuromodulators in Irritable Bowel Syndrome: Why, How, and When. Am J Gastroenterol 2024; 119:1272-1284. [PMID: 38595149 PMCID: PMC11208063 DOI: 10.14309/ajg.0000000000002800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/04/2024] [Indexed: 04/11/2024]
Abstract
Irritable bowel syndrome (IBS) is responsive to treatments using central neuromodulators. Central neuromodulators work by enhancing the synaptic transmission of 5-hydroxytryptamine, noradrenalin, and dopamine, achieving a slower regulation or desensitization of their postsynaptic receptors. Central neuromodulators act on receptors along the brain-gut axis, so they are useful in treating psychiatric comorbidities, modifying gut motility, improving central downregulation of visceral signals, and enhancing neurogenesis in patients with IBS. Choosing a central neuromodulator for treating IBS should be according to the pharmacological properties and predominant symptoms. The first-line treatment for pain management in IBS is using tricyclic antidepressants. An alternative for pain management is the serotonin and noradrenaline reuptake inhibitors. Selective serotonin reuptake inhibitors are useful when symptoms of anxiety and hypervigilance are dominant but are not helpful for treating abdominal pain. The predominant bowel habit is helpful when choosing a neuromodulator to treat IBS; selective serotonin reuptake inhibitors help constipation, not pain, but may cause diarrhea; tricyclic antidepressants help diarrhea but may cause constipation. A clinical response may occur in 6-8 weeks, but long-term treatment (usually 6-12 months) is required after the initial response to prevent relapse. Augmentation therapy may be beneficial when the therapeutic effect of the first agent is incomplete or associated with side effects. It is recommended to reduce the dose of the first agent and add a second complementary treatment. This may include an atypical antipsychotic or brain-gut behavioral treatment. When tapering central neuromodulators, the dose should be reduced slowly over 4 weeks but may take longer when discontinuation effects occur.
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Affiliation(s)
- Ignacio Hanna-Jairala
- Division of Gastroenterology, Department of Internal Medicine, Hospital Alcivar, Guayaquil, Ecuador
| | - Douglas A. Drossman
- Center for Education and Practice of Biopsychosocial Care, Drossman Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
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Tong X, Zhao K, Fonzo GA, Xie H, Carlisle NB, Keller CJ, Oathes DJ, Sheline Y, Nemeroff CB, Williams LM, Trivedi M, Etkin A, Zhang Y. Optimizing Antidepressant Efficacy: Multimodal Neuroimaging Biomarkers for Prediction of Treatment Response. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.11.24305583. [PMID: 38645124 PMCID: PMC11030479 DOI: 10.1101/2024.04.11.24305583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Major depressive disorder (MDD) is a common and often severe condition that profoundly diminishes quality of life for individuals across ages and demographic groups. Unfortunately, current antidepressant and psychotherapeutic treatments exhibit limited efficacy and unsatisfactory response rates in a substantial number of patients. The development of effective therapies for MDD is hindered by the insufficiently understood heterogeneity within the disorder and its elusive underlying mechanisms. To address these challenges, we present a target-oriented multimodal fusion framework that robustly predicts antidepressant response by integrating structural and functional connectivity data (sertraline: R2 = 0.31; placebo: R2 = 0.22). Through the model, we identify multimodal neuroimaging biomarkers of antidepressant response and observe that sertraline and placebo show distinct predictive patterns. We further decompose the overall predictive patterns into constitutive network constellations with generalizable structural-functional co-variation, which exhibit treatment-specific association with personality traits and behavioral/cognitive task performance. Our innovative and interpretable multimodal framework provides novel insights into the intricate neuropsychopharmacology of antidepressant treatment and paves the way for advances in precision medicine and development of more targeted antidepressant therapeutics.
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Affiliation(s)
- Xiaoyu Tong
- Department of Bioengineering, Lehigh University, Bethlehem, PA, USA
| | - Kanhao Zhao
- Department of Bioengineering, Lehigh University, Bethlehem, PA, USA
| | - Gregory A. Fonzo
- Center for Psychedelic Research and Therapy, Department of Psychiatry and Behavioral Sciences, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Hua Xie
- Center for Neuroscience Research, Children’s National Hospital, Washington, DC, USA
| | | | - Corey J. Keller
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Sierra-Pacific Mental Illness Research, Education and Clinical Center (MIRECC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Desmond J. Oathes
- Center for Brain Imaging and Stimulation, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yvette Sheline
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles B. Nemeroff
- Center for Psychedelic Research and Therapy, Department of Psychiatry and Behavioral Sciences, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Leanne M. Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Sierra-Pacific Mental Illness Research, Education and Clinical Center (MIRECC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Madhukar Trivedi
- Department of Psychiatry, Center for Depression Research and Clinical Care, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amit Etkin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Alto Neuroscience, Inc., Los Altos, CA, USA
| | - Yu Zhang
- Department of Bioengineering, Lehigh University, Bethlehem, PA, USA
- Department of Electrical and Computer Engineering, Lehigh University, Bethlehem, PA, USA
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Liu L, Wang H, Zhang H, Chen X, Zhang Y, Wu J, Zhao L, Wang D, Pu J, Ji P, Xie P. Toward a Deeper Understanding of Gut Microbiome in Depression: The Promise of Clinical Applicability. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2203707. [PMID: 36285702 PMCID: PMC9762301 DOI: 10.1002/advs.202203707] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/15/2022] [Indexed: 05/30/2023]
Abstract
The emergence of the coronavirus disease 2019 pandemic has dramatically increased the global prevalence of depression. Unfortunately, antidepressant drugs benefit only a small minority of patients. Thus, there is an urgent need to develop new interventions. Accumulating evidence supports a causal relationship between gut microbiota dysbiosis and depression. To advance microbiota-based diagnostics and therapeutics of depression, a comprehensive overview of microbial alterations in depression is presented to identify effector microbial biomarkers. This procedure generated 215 bacterial taxa from humans and 312 from animal models. Compared to controls, depression shows significant differences in β-diversity, but no changes in microbial richness and diversity. Additionally, species-specific microbial changes are identified like increased Eggerthella in humans and decreased Acetatifactor in rodent models. Moreover, a disrupted microbiome balance and functional changes, characterized by an enrichment of pro-inflammatory bacteria (e.g., Desulfovibrio and Escherichia/Shigella) and depletion of anti-inflammatory butyrate-producing bacteria (e.g., Bifidobacterium and Faecalibacterium) are consistently shared across species. Confounding effects of geographical region, depression type, and intestinal segments are also investigated. Ultimately, a total of 178 species and subspecies probiotics are identified to alleviate the depressive phenotypes. Current findings provide a foundation for developing microbiota-based diagnostics and therapeutics and advancing microbiota-oriented precision medicine for depression.
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Affiliation(s)
- Lanxiang Liu
- Department of NeurologyYongchuan Hospital of Chongqing Medical UniversityChongqing402160China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Haiyang Wang
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- College of Stomatology and Affiliated Stomatological Hospital of Chongqing Medical UniversityChongqing401147China
| | - Hanping Zhang
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Xueyi Chen
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Yangdong Zhang
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Ji Wu
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Libo Zhao
- Department of NeurologyYongchuan Hospital of Chongqing Medical UniversityChongqing402160China
| | - Dongfang Wang
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Juncai Pu
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Ping Ji
- College of Stomatology and Affiliated Stomatological Hospital of Chongqing Medical UniversityChongqing401147China
| | - Peng Xie
- Department of NeurologyYongchuan Hospital of Chongqing Medical UniversityChongqing402160China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional DiseasesThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- College of Stomatology and Affiliated Stomatological Hospital of Chongqing Medical UniversityChongqing401147China
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Kato M, Hori H, Inoue T, Iga J, Iwata M, Inagaki T, Shinohara K, Imai H, Murata A, Mishima K, Tajika A. Discontinuation of antidepressants after remission with antidepressant medication in major depressive disorder: a systematic review and meta-analysis. Mol Psychiatry 2021; 26:118-133. [PMID: 32704061 PMCID: PMC7815511 DOI: 10.1038/s41380-020-0843-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 12/25/2022]
Abstract
A significant clinical issue encountered after a successful acute major depressive disorder (MDD) treatment is the relapse of depressive symptoms. Although continuing maintenance therapy with antidepressants is generally recommended, there is no established protocol on whether or not it is necessary to prescribe the antidepressant used to achieve remission. In this meta-analysis, the risk of relapse and treatment failure when either continuing with the same drug used to achieved remission or switching to a placebo was assessed in several clinically significant subgroups. The pooled odds ratio (OR) (±95% confidence intervals (CI)) was calculated using a random effects model. Across 40 studies (n = 8890), the relapse rate was significantly lower in the antidepressant group than the placebo group by about 20% (OR = 0.38, CI: 0.33-0.43, p < 0.00001; 20.9% vs 39.7%). The difference in the relapse rate between the antidepressant and placebo groups was greater for tricyclics (25.3%; OR = 0.30, CI: 0.17-0.50, p < 0.00001), SSRIs (21.8%; OR = 0.33, CI: 0.28-0.38, p < 0.00001), and other newer agents (16.0%; OR = 0.44, CI: 0.36-0.54, p < 0.00001) in that order, while the effect size of acceptability was greater for SSRIs than for other antidepressants. A flexible dose schedule (OR = 0.30, CI: 0.23-0.48, p < 0.00001) had a greater effect size than a fixed dose (OR = 0.41, CI: 0.36-0.48, p < 0.00001) in comparison to placebo. Even in studies assigned after continuous treatment for more than 6 months after remission, the continued use of antidepressants had a lower relapse rate than the use of a placebo (OR = 0.40, CI: 0.29-0.55, p < 0.00001; 20.2% vs 37.2%). The difference in relapse rate was similar from a maintenance period of 6 months (OR = 0.41, CI: 0.35-0.48, p < 0.00001; 19.6% vs 37.6%) to over 1 year (OR = 0.35, CI: 0.29-0.41, p < 0.00001; 19.9% vs 39.8%). The all-cause dropout of antidepressant and placebo groups was 43% and 58%, respectively, (OR = 0.47, CI: 0.40-0.55, p < 0.00001). The tolerability rate was ~4% for both groups. The rate of relapse (OR = 0.32, CI: 0.18-0.64, p = 0.0010, 41.0% vs 66.7%) and all-cause dropout among adolescents was higher than in adults. To prevent relapse and treatment failure, maintenance therapy, and careful attention for at least 6 months after remission is recommended. SSRIs are well-balanced agents, and flexible dose adjustments are more effective for relapse prevention.
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Affiliation(s)
- Masaki Kato
- Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan.
| | - Hikaru Hori
- Department of Psychiatry, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Junichi Iga
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Masaaki Iwata
- Department of Neuropsychiatry, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Takahiko Inagaki
- Adolescent Mental Health Service, Biwako Hospital, Otsu, Japan.,Department of Psychiatry, Shiga University of Medical Science, Otsu, Japan
| | - Kiyomi Shinohara
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and School of Public Health, Kyoto, Japan
| | - Hissei Imai
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and School of Public Health, Kyoto, Japan
| | - Atsunobu Murata
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Aran Tajika
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
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Depressive Disorders and Sleeping Disturbances-Surveys Study of 923 Participants on the Pol'and'Rock Festival, Kostrzyn, Poland 2019. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218092. [PMID: 33153051 PMCID: PMC7663019 DOI: 10.3390/ijerph17218092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/15/2020] [Accepted: 10/26/2020] [Indexed: 01/01/2023]
Abstract
Depressive disorders are common among young people and can decrease social competences and thus the quality of life. There is a relationship between the occurrence of depressive disorders and insomnia. The aim of the study was to determine the prevalence of insomnia and depressive behavior and assess the relationship between these among participants of the Pol’and’Rock Festival, Kostrzyn, Poland 2019. The study used the Athens Insomnia Scale (AIS) and the Beck Inventory II Scale (BDI-II). The study group consisted of 923 people, with the majority of women (n = 500; 54.2%). A total of 297 persons (32.2%) reported varying severity of depressive symptoms. Insomnia was observed in 261 (28.28%) respondents. Sleeping disturbances were observed more frequently in females. Persons with insomnia had a significantly higher BDI-II score. A strong positive correlation (r = 0.65) between the number of points obtained on the Beck and AIS scales was observed. Insomnia and depressive behavior are prevalent in the Polish population. Due to long-term social and economic consequences, special attention should be paid to the prevention, early detection and treatment of both disorders.
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Zhou Y, Chen C, Yu H, Yang Z. Fecal Microbiota Changes in Patients With Postpartum Depressive Disorder. Front Cell Infect Microbiol 2020; 10:567268. [PMID: 33134190 PMCID: PMC7550660 DOI: 10.3389/fcimb.2020.567268] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/17/2020] [Indexed: 12/19/2022] Open
Abstract
Postpartum depressive disorder (PPD) is a unique subtype of major depressive disorder and a substantial contributor to maternal morbidity and mortality. However, the pathogenesis of PPD has still remained elusive, and it may associate with genetic and environmental factors. Gut microbiota has already been proved to be associated with depression; however, a limited number of studies have concentrated on PPD. The present study aimed to explore the potential correlations between gut microbiota and PPD. In this study, 57 participants were enrolled, in which fecal samples of 28 patients with PPD and 16 healthy controls (HCs) were collected and then analyzed by high-throughput sequencing of the 16S ribosomal RNA (rRNA) gene. The results showed that diversity and composition of gut microbial communities were partly different between PPD patients and HCs. The relative abundance of Firmicutes phyla was lower in PPD patients. The levels of several predominant genera were significantly different between PPD patients and HCs. More importantly, the PPD patients experienced reduced levels of Faecalibacterium, Phascolarctobacterium, Butyricicoccus, and Lachnospiraceae, as well as increased levels of Enterobacteriaceae family. In addition, a correlation was observed between levels of Phascolarctobacterium, Lachnospiraceae, Faecalibacterium, and Tyzzerella.3 and the severity of depressive symptoms. Various kinds of bacteria, such as Lachnospiraceae and Faecalibacterium, were found to be associated with levels of sex hormones. This study indicated the correlation between gut microbiota and PPD, and gut microbiota-based biomarkers may be helpful for the diagnosis and treatment of PPD patients. However, further studies need to be conducted to clarify the cause–effect relationship between PPD patients and gut microbiota and to highlight the suitability of gut microbiome as a biomarker.
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Affiliation(s)
- Yumei Zhou
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Chen Chen
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Haibo Yu
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Zhuoxin Yang
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
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Freedland KE, Steinmeyer BC, Carney RM, Skala JA, Rich MW. Antidepressant use in patients with heart failure. Gen Hosp Psychiatry 2020; 65:1-8. [PMID: 32361659 PMCID: PMC7350278 DOI: 10.1016/j.genhosppsych.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE There is little evidence that antidepressants are efficacious for depression in patients with heart failure (HF), and equivocal evidence that they are safe. This study identified characteristics that are associated with antidepressant use in hospitalized patients with HF. METHOD Logistic regression models were used to identify independent correlates of antidepressant use in 400 patients hospitalized with HF between 2014 and 2016. The measure of depression in the primary analysis was a DSM-5 diagnosis based on a structured interview; this was replaced by a PHQ-9 depression score in a secondary analysis. RESULTS In the primary analysis, there were positive associations between antidepressant use and white race, younger age, unemployment, non-ischemic HF, number of other prescribed medications, current minor depression, history of major depression, and functional impairment. In the secondary analysis, there were positive associations with white race, unemployment, number of other prescribed medications, and functional impairment; the effect of current severity of depression differed between patients with vs. without a history of major depression. CONCLUSIONS Current depression is only one of several factors that influence the use of antidepressant medications in patients with HF. Further research is needed to ensure that these agents are being used appropriately in this patient population.
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Affiliation(s)
- Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.
| | - Brian C Steinmeyer
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert M Carney
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Judith A Skala
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael W Rich
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Nuggerud-Galeas S, Sáez-Benito Suescun L, Berenguer Torrijo N, Sáez-Benito Suescun A, Aguilar-Latorre A, Magallón Botaya R, Oliván Blázquez B. Analysis of depressive episodes, their recurrence and pharmacologic treatment in primary care patients: A retrospective descriptive study. PLoS One 2020; 15:e0233454. [PMID: 32437398 PMCID: PMC7241802 DOI: 10.1371/journal.pone.0233454] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/05/2020] [Indexed: 11/29/2022] Open
Abstract
Background Depression is one of the most prevalent health problems, frequently being a medium- and long-term condition, with a high comorbidity rate and with frequent relapses and recurrences. Although numerous studies have compared the effectiveness of specific antidepressant therapy drugs and have assessed relapses, scientific evidence on the relationship between pharmacologic treatments and recurrence is scarce. The objective of this study is to describe depressive episodes in a primary care patient cohort, the percentage of depression recurrences and the administered pharmacologic treatment, from a naturalistic perspective. Methods Retrospective descriptive study. 957 subjects were included. The dependent variable was a depression diagnosis and independent variables were: gender, age at time of data collection; age of onset, first-episode treatment, number of recurrences, age at recurrences, treatment prescribed for recurrences using therapeutic groups categorization. Results Recurrences are frequent, affecting more than 40% of the population. In the first episode, 13.69% of the patients were not prescribed pharmacological treatment, but this percentage decreased over the following depression episodes. 80.9% of the patients who did not receive drug treatment in the first depression episode did not experience subsequent episodes. Monotherapy, and specifically, SSRIs were the most frequently prescribed treatment option for all depressive episodes. Regards the combined pharmacologic treatment, the most frequent drug combinations were SSRIs and benzodiazepines. Limitations In order to increase the power of results, the statistical analysis was performed using therapeutic groups categorization, not individually analyzing each drug and dose. Conclusions Depressive episode recurrence is frequent in primary care patients. Further studies having a prospective design are needed in order to expand on this issue.
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Affiliation(s)
| | | | | | | | | | - Rosa Magallón Botaya
- Institute for Health Research Aragón, Zaragoza, Spain
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain
- * E-mail: ,
| | - Bárbara Oliván Blázquez
- Institute for Health Research Aragón, Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain
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Hengartner MP. How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding. Ther Adv Psychopharmacol 2020; 10:2045125320921694. [PMID: 32435449 PMCID: PMC7225779 DOI: 10.1177/2045125320921694] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/27/2020] [Indexed: 12/20/2022] Open
Abstract
The aim of this article is to discuss the validity of relapse prevention trials and the issue of withdrawal confounding in these trials. Recommendations for long-term antidepressant treatment are based almost exclusively on discontinuation trials. In these relapse prevention trials, participants with remitted depression are randomised either to have the antidepressant abruptly discontinued and replaced by inert placebo or to continue active treatment. The drug-placebo difference in relapse rates at the end of the maintenance phase is then interpreted as a prophylactic drug effect. These trials consistently produce remarkable benefits for maintenance treatment. However, the internal validity of this trial protocol is compromised, as research has shown that abruptly stopping antidepressants can cause severe withdrawal reactions that lead to (or manifest as) depression relapses. That is, there is substantial withdrawal confounding in discontinuation trials, which renders their findings uninterpretable. It is not clear to what degree the drug-placebo separation in relapse prevention (discontinuation) trials is due to withdrawal reactions, but various estimations suggest that it is presumably the majority. A review of findings based on other methodologies, including real-world long-term effectiveness trials like STAR*D and various naturalistic cohort studies, do not indicate that antidepressants have considerable prophylactic effects. As absence of evidence does not imply evidence of absence, no definitive conclusions can be drawn from the literature. To enable a thorough risk-benefit evaluation, real-world effectiveness trials should not only focus on relapse prevention, but also assess antidepressants' long-term effects on social functioning and quality of life. Thus far, reliable long-term data on these outcome domains are lacking.
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Affiliation(s)
- Michael P. Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), PO Box 707, Zurich, CH-8037, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
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Vittengl JR, Clark LA, Thase ME, Jarrett RB. Could Treatment Matching Patients' Beliefs About Depression Improve Outcomes? Behav Ther 2019; 50:765-777. [PMID: 31208686 PMCID: PMC6582988 DOI: 10.1016/j.beth.2018.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 11/09/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
Patients' beliefs about depression and expectations for treatment can influence outcomes of major depressive disorder (MDD) treatments. We hypothesized that patients with weaker biological beliefs (less endorsement of [a] biochemical causes and [b] need for medication) and more optimistic treatment expectations (greater improvement and shorter time to improvement), have better outcomes in cognitive therapy (CT). Outpatients with recurrent MDD who received acute-phase CT (N = 152), and a subset of partial or unstable responders (N = 51) randomized to 8 months of continuation CT or fluoxetine with clinical management, completed repeated measures of beliefs, expectations, and depression. As hypothesized, patients with weaker biological beliefs about depression, and patients who expected a shorter time to improvement, experienced greater change in depressive symptoms and more frequent response to acute-phase CT. Moreover, responders who received continuation treatment better matched to their biological beliefs (i.e., responders with weaker biological beliefs about depression who received continuation CT, or responders with stronger biological beliefs about depression who received continuation fluoxetine) had fewer depressive symptoms and less relapse/recurrence by 32 months after acute-phase CT than did responders who received mismatched continuation treatment. Specific screening and/or intervention targeting patients' biological beliefs about depression could increase CT efficacy.
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Shinohara K, Efthimiou O, Ostinelli EG, Tomlinson A, Geddes JR, Nierenberg AA, Ruhe HG, Furukawa TA, Cipriani A. Comparative efficacy and acceptability of antidepressants in the long-term treatment of major depression: protocol for a systematic review and networkmeta-analysis. BMJ Open 2019; 9:e027574. [PMID: 31110100 PMCID: PMC6530313 DOI: 10.1136/bmjopen-2018-027574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/22/2019] [Accepted: 03/27/2019] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Pharmacotherapy plays an important role in the treatment of major depression. At the initiation of antidepressant treatment, both improvement of symptoms in the short term and relapse prevention in the long term should be taken into account. However, there is insufficient evidence regarding the efficacy and the acceptability of continuation/maintenance treatments and the relative efficacy/acceptability of antidepressants. OBJECTIVE We will conduct a pairwise meta-analysis and a network meta-analysis (NMA) to examine the relative efficacy, tolerability and acceptability of antidepressants in the long-term treatment of major depression. METHODS AND ANALYSIS We will include double-blind randomised controlled trials comparing any of the following antidepressants, which we included in our previous NMA of the acute treatment for major depression, with placebo or with another active drug for long-term treatment of major depression: agomelatine, amitriptyline, bupropion, citalopram, clomipramine, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, trazodone, venlafaxine, vilazodone and vortioxetine. Our primary outcomes will be sustained response and all-cause dropouts. We will include four types of designs that are used to investigate long-term treatment. We will conduct two main analyses. First, we will conduct a pairwise meta-analysis comparing all antidepressants versus placebo to investigate whether continuing antidepressants after achieving a positive response in the acute-phase treatment is beneficial and/or safe. Second, we will conduct an NMA to examine the comparative efficacy and acceptability of the drugs. We will use a novel approach that will combine the results of acute-phase treatment NMA with long-term treatment studies to include all related designs in the NMA. We will ensure the validity of combining different designs and our new approach by checking the distribution of important effect modifiers and consistency of network. ETHICS AND DISSEMINATION This study did not require ethical approval. We will disseminate our findings by publishing results in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018114561; Pre-results.
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Affiliation(s)
- Kiyomi Shinohara
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - John R Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Henricus G Ruhe
- Department of Psychiatry, Radboud University, Nijmegen, the Netherlands
| | - Toshi A Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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12
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Lukić I, Getselter D, Ziv O, Oron O, Reuveni E, Koren O, Elliott E. Antidepressants affect gut microbiota and Ruminococcus flavefaciens is able to abolish their effects on depressive-like behavior. Transl Psychiatry 2019; 9:133. [PMID: 30967529 PMCID: PMC6456569 DOI: 10.1038/s41398-019-0466-x] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 02/28/2019] [Accepted: 03/23/2019] [Indexed: 12/22/2022] Open
Abstract
Accumulating evidence demonstrates that the gut microbiota affects brain function and behavior, including depressive behavior. Antidepressants are the main drugs used for treatment of depression. We hypothesized that antidepressant treatment could modify gut microbiota which can partially mediate their antidepressant effects. Mice were chronically treated with one of five antidepressants (fluoxetine, escitalopram, venlafaxine, duloxetine or desipramine), and gut microbiota was analyzed, using 16s rRNA gene sequencing. After characterization of differences in the microbiota, chosen bacterial species were supplemented to vehicle and antidepressant-treated mice, and depressive-like behavior was assessed to determine bacterial effects. RNA-seq analysis was performed to determine effects of bacterial treatment in the brain. Antidepressants reduced richness and increased beta diversity of gut bacteria, compared to controls. At the genus level, antidepressants reduced abundances of Ruminococcus, Adlercreutzia, and an unclassified Alphaproteobacteria. To examine implications of the dysregulated bacteria, we chose one of antidepressants (duloxetine) and investigated if its antidepressive effects can be attenuated by simultaneous treatment with Ruminococcus flavefaciens or Adlercreutzia equolifaciens. Supplementation with R. flavefaciens diminished duloxetine-induced decrease in depressive-like behavior, while A. equolifaciens had no such effect. R. flavefaciens treatment induced changes in cortical gene expression, up-regulating genes involved in mitochondrial oxidative phosphorylation, while down-regulating genes involved in neuronal plasticity. Our results demonstrate that various types of antidepressants alter gut microbiota composition, and further implicate a role for R. flavefaciens in alleviating depressive-like behavior. Moreover, R. flavefaciens affects gene networks in the brain, suggesting a mechanism for microbial regulation of antidepressant treatment efficiency.
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Affiliation(s)
- Iva Lukić
- 0000 0004 1937 0503grid.22098.31Molecular and Behavioral Neuroscience, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel
| | - Dmitriy Getselter
- 0000 0004 1937 0503grid.22098.31Molecular and Behavioral Neuroscience, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel
| | - Oren Ziv
- 0000 0004 1937 0503grid.22098.31Microbiome Research, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel
| | - Oded Oron
- 0000 0004 1937 0503grid.22098.31Molecular and Behavioral Neuroscience, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel
| | - Eli Reuveni
- 0000 0004 1937 0503grid.22098.31Drug discovery Laboratories, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel
| | - Omry Koren
- 0000 0004 1937 0503grid.22098.31Microbiome Research, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel
| | - Evan Elliott
- Molecular and Behavioral Neuroscience, The Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold St. 8, Safed, Israel.
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13
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van Bronswijk SC, Lemmens LH, Keefe JR, Huibers MJ, DeRubeis RJ, Peeters FP. A prognostic index for long-term outcome after successful acute phase cognitive therapy and interpersonal psychotherapy for major depressive disorder. Depress Anxiety 2019; 36:252-261. [PMID: 30516871 PMCID: PMC6587800 DOI: 10.1002/da.22868] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 10/21/2018] [Accepted: 11/08/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) has a highly recurrent nature. After successful treatment, it is important to identify individuals who are at risk of an unfavorable long-term course. Despite extensive research, there is no consensus yet on the clinically relevant predictors of long-term outcome in MDD, and no prediction models are implemented in clinical practice. The aim of this study was to create a prognostic index (PI) to estimate long-term depression severity after successful and high quality acute treatment for MDD. METHODS Data come from responders to cognitive therapy (CT) and interpersonal psychotherapy (IPT) in a randomized clinical trial (n = 85; CT = 45, IPT = 40). Primary outcome was depression severity, assessed with the Beck Depression Inventory II, measured throughout a 17-month follow-up phase. We examined 29 variables as potential predictors, using a model-based recursive partitioning method and bootstrap resampling in conjunction with backwards elimination. The selected predictors were combined into a PI. Individual PI scores were estimated using a cross-validation approach. RESULTS A total of three post-treatment predictors were identified: depression severity, hopelessness, and self-esteem. Cross-validated PI scores evidenced a strong correlation (r = 0.60) with follow-up depression severity. CONCLUSION Long-term predictions of MDD are multifactorial, involving a combination of variables that each has a small prognostic effect. If replicated and validated, the PI can be implemented to predict follow-up depression severity for each individual after acute treatment response, and to personalize long-term treatment strategies.
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Affiliation(s)
- Suzanne C. van Bronswijk
- Department of Psychiatry and PsychologyMaastricht University Medical CenterMaastrichtthe Netherlands,School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityMaastrichtthe Netherlands
| | - Lotte H.J.M. Lemmens
- Department of Clinical Psychological ScienceMaastricht UniversityMaastrichtthe Netherlands
| | - John R. Keefe
- Department of PsychologyUniversity of PennsylvaniaPhiladelphiaPAUnited States,Department of PsychiatryWeill Cornell Medical CollegeNew YorkUnited States
| | - Marcus J.H. Huibers
- Department of PsychologyUniversity of PennsylvaniaPhiladelphiaPAUnited States,Department of Clinical PsychologyVU University AmsterdamAmsterdamthe Netherlands
| | - Robert J. DeRubeis
- Department of PsychologyUniversity of PennsylvaniaPhiladelphiaPAUnited States
| | - Frenk P.M.L. Peeters
- Department of Psychiatry and PsychologyMaastricht University Medical CenterMaastrichtthe Netherlands,School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityMaastrichtthe Netherlands
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14
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Biesheuvel-Leliefeld KEM, Dijkstra-Kersten SMA, van Schaik DJF, van Marwijk HWJ, Smit F, van der Horst HE, Bockting CLH. Effectiveness of Supported Self-Help in Recurrent Depression: A Randomized Controlled Trial in Primary Care. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018. [PMID: 28647744 DOI: 10.1159/000472260] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The burden and economic consequences of depression are high, mostly due to its recurrent nature. Due to current budget and time restraints, a preventive, low- cost, accessible minimal intervention is much needed. In this study, we evaluated the effectiveness of a supported self-help preventive cognitive therapy (S-PCT) added to treatment as usual (TAU) in primary care, compared to TAU alone. METHODS We conducted a randomized controlled trial among 248 patients with a history of depression, currently in full or partial remission or recovery. Participants were randomized to TAU augmented with S-PCT (n = 124) or TAU alone (n = 124). S-PCT consisted of an 8-week self-help intervention, supported by weekly telephone guidance by a counselor. The intervention included a self-help book that could be read at home. The primary outcome was the incidence of relapse or recurrence and was assessed over the telephone by the Structured Clinical Interview for DSM-IV axis 1 disorders. Participants were observed for 12 months. Secondary outcomes were depressive symptoms, quality of life (EQ-5D and SF-12), comorbid psychopathology, and self-efficacy. These secondary outcomes were assessed by digital questionnaires. RESULTS In the S-PCT group, 44 participants (35.5%) experienced a relapse or recurrence, compared to 62 participants (50.0%) in the TAU group (incidence rate ratio = 0.71, 95% CI 0.52-0.97; risk difference = 14, 95% CI 2-24, number needed to treat = 7). Compared to the TAU group, the S-PCT group showed a significant reduction in depressive symptoms over 12 months (mean difference -2.18; 95% CI -3.09 to -1.27) and a significant increase in quality of life (EQ-5D) (mean difference 0.04; 95% CI 0.004-0.08). S-PCT had no effect on comorbid psychopathology, self-efficacy, and quality of life based on the SF-12. CONCLUSIONS A supported self-help preventive cognitive therapy, guided by a counselor in primary care, proved to be effective in reducing the burden of recurrent depression.
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15
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Seeberg I, Kjaerstad HL, Miskowiak KW. Neural and Behavioral Predictors of Treatment Efficacy on Mood Symptoms and Cognition in Mood Disorders: A Systematic Review. Front Psychiatry 2018; 9:337. [PMID: 30093870 PMCID: PMC6071514 DOI: 10.3389/fpsyt.2018.00337] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/03/2018] [Indexed: 12/19/2022] Open
Abstract
Background: The clinical and etiological heterogeneity of mood disorders impede identification of effective treatments for the individual patient. This highlights a need for early neuronal and behavioral biomarkers for treatment efficacy, which can provide a basis for more personalized treatments. The present systematic review aimed to identify the most consistent neuronal and behavioral predictors of treatment efficacy on mood symptoms and cognitive impairment in mood disorders. Methods: We identified and included 60 original peer-reviewed studies investigating neuroimaging and behavioral predictors of treatment efficacy within the domains of emotional and non-emotional cognition, structural neuroimaging, and resting state functional connectivity in patients with unipolar or bipolar disorder. Results: Lower baseline responsivity in limbic regions coupled with heightened medial and dorsal prefrontal responses to emotional stimuli were the most consistent predictors of response to pharmacotherapy for depression. In contrast, heightened limbic and ventral prefrontal reactivity to emotional stimuli seemed to predict efficacy of psychological interventions. Early modulation of fronto-limbic activity and reduction in negative bias were also associated with treatment response. Better performance on non-emotional tests at baseline was relatively consistently associated with efficacy on mood symptoms, whereas the association between neural activity during non-emotional tests and treatment response was less clear. Other baseline factors associated with treatment response were greater white matter integrity, resting state functional connectivity, more prefrontal gray matter volume as well as an early increase following short administered treatment. Finally, emerging evidence indicates that baseline cognitive deficits are associated with greater chances of achieving treatment efficacy on cognition. Conclusions: Patients' profile of emotional and non-emotional cognition and neural activity-and the early treatment-associated changes in neural and cognitive function-may be useful for guiding treatments for depression. While cognitive deficits at baseline seem to improve chances of treatment efficacy on cognition, more studies of this association are urgently needed.
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Affiliation(s)
- Ida Seeberg
- Neurocognition and Emotion in Affective Disorders Group, Copenhagen Affective Disorder Research Centre, Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Hanne L Kjaerstad
- Neurocognition and Emotion in Affective Disorders Group, Copenhagen Affective Disorder Research Centre, Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kamilla W Miskowiak
- Neurocognition and Emotion in Affective Disorders Group, Copenhagen Affective Disorder Research Centre, Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Psychology, University of Copenhagen, Copenhagen, Denmark
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16
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Dickerson JF, Feeny DH, Clarke GN, MacMillan AL, Lynch FL. Evidence on the longitudinal construct validity of major generic and utility measures of health-related quality of life in teens with depression. Qual Life Res 2017; 27:447-454. [PMID: 29149441 DOI: 10.1007/s11136-017-1728-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine the longitudinal construct validity in the assessment of changes in depressive symptoms of widely used utility and generic HRQL instruments in teens. METHODS 392 teens enrolled in the study and completed HRQL and diagnostic measures as part of the baseline interview. HRQL measures included EuroQol (EQ-5D-3L), Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), Quality of Well-Being Scale (QWB), Pediatric Quality of Life Inventory (PEDS-QL), RAND-36 (SF-6D), and Quality of Life in Depression Scale (QLDS). Youth completed follow-up interviews 12 weeks after baseline. Sixteen youth (4.1%) were lost to follow-up. We examined correlations between changes in HRQL instruments and the Children's Depression Rating Scale-Revised (CDRS-R) and assessed clinically meaningful change in multi-attribute utility HRQL measures using mean change (MC) and standardized response mean (SRM) among youth showing at least moderate (20%) improvement in depression symptomology. RESULTS Spearman's correlation coefficients demonstrated moderate correlation between changes in CDRS-R and the HUI2 (r = 0.38), HUI3 (r = 0.42), EQ-5D-3L (r = 0.36), SF-6D (r = 0.39), and PEDS-QL (r = 0.39) and strong correlation between changes in CDRS-R and QWB (r = 0.52) and QLDS (r = - 0.71). Effect size results are also reported. Among multi-attribute utility measures, all showed clinically meaningful improvements in the sample of youth with depression improvement (HUI2, MC = 0.20, SRM = 0.97; HUI3, MC = 0.32, SRM = 1.17; EQ-5D-3L, MC = 0.08, SRM = 0.51; QWB, MC = 0.11, SRM = 0.86; and SF-6D, MC = 0.12, SRM = 1.02). CONCLUSIONS Findings support the longitudinal construct validity of included HRQL instruments for the assessment of change in depression outcomes in teens. Results of this study can help inform researchers about viable instruments to include in economic evaluations for this population.
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Affiliation(s)
- John F Dickerson
- Center for Health Research - Kaiser Permanente, 3800 N. Interstate Ave., Portland, OR, 97227, USA.
| | - David H Feeny
- Department of Economics, McMaster University, Hamilton, ON, Canada
- Health Utilities Incorporated, Dundas, ON, Canada
| | - Gregory N Clarke
- Center for Health Research - Kaiser Permanente, 3800 N. Interstate Ave., Portland, OR, 97227, USA
| | - Alex L MacMillan
- ThinkShout, Inc, 433 NW 4th Ave, Suite 100, Portland, OR, 97209, USA
| | - Frances L Lynch
- Center for Health Research - Kaiser Permanente, 3800 N. Interstate Ave., Portland, OR, 97227, USA
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17
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Slofstra C, Klein NS, Nauta MH, Wichers M, Batalas N, Bockting CL. Imagine your mood: Study design and protocol of a randomized controlled micro-trial using app-based experience sampling methodology to explore processes of change during relapse prevention interventions for recurrent depression. Contemp Clin Trials Commun 2017; 7:172-178. [PMID: 29696182 PMCID: PMC5898558 DOI: 10.1016/j.conctc.2017.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/03/2017] [Accepted: 07/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background Relapse prevention strategies include continuation of antidepressant medication and preventive psychological interventions. This study aims to gain understanding that may inform tailoring of relapse prevention to individual differences, to improve their effects. Such treatment personalization may be based on repeated assessments within one individual, using experience sampling methodology. As a first step towards informing decisions based on this methodology, insight is needed in individual differences in risk of relapse and response to treatment, and how relapse prevention strategies may differentially target vulnerability for relapse. Methods The smartphone application ‘Imagine your mood’ has been developed specifically for this study to assess emotions, imagery, cognitions, and behaviors in daily life. Parallel to the randomized controlled trial ‘Disrupting the rhythm of depression’, 45 remitted recurrently depressed individuals taking continuation antidepressant medication will be randomly assigned to either continuing antidepressant medication (n = 15), continuing antidepressant medication combined with an eight-session preventive cognitive therapy (n = 15), or tapering of antidepressant medication in combination with preventive cognitive therapy (n = 15). Relapse and return of depressive symptomatology over a 24-month follow-up will be assessed. Additionally, matched never depressed individuals (n = 15) will be recruited as controls. Discussion This innovative study combines the strengths of a randomized controlled trial and experience sampling methodology in a micro-trial to explore individual differences in risk of relapse and what works for whom to prevent relapse. Results may ultimately pave the way for therapists to tailor relapse prevention strategies to individual (affective) vulnerability. Trial registration ISRCTN15472145, retrospectively registered.
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Affiliation(s)
- Christien Slofstra
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
| | - Nicola S. Klein
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
| | - Maaike H. Nauta
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
| | - Marieke Wichers
- University of Groningen, University Medical Center Groningen (UMCG), Department of Psychiatry (UCP), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), 9700 RB, Groningen, The Netherlands
| | - Nikolaos Batalas
- Department of Industrial Design, Eindhoven University of Technology, 5612 AZ, Eindhoven, The Netherlands
| | - Claudi L.H. Bockting
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
- Department of Clinical Psychology, Utrecht University, 3508 TC, Utrecht, The Netherlands
- Corresponding author. Department of Clinical & Health Psychology, Utrecht University, 3508 TC, Utrecht, The Netherlands.
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18
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Vittengl JR, Clark LA, Thase ME, Jarrett RB. Initial Steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder. Psychiatry Res 2017; 253:174-181. [PMID: 28388454 PMCID: PMC5481171 DOI: 10.1016/j.psychres.2017.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
Responders to acute-phase cognitive therapy (A-CT) for major depressive disorder (MDD) often relapse or recur, but continuation-phase cognitive therapy (C-CT) or fluoxetine reduces risks for some patients. We tested composite moderators of C-CT versus fluoxetine's preventive effects to inform continuation treatment selection. Responders to A-CT for MDD judged to be at higher risk for relapse due to unstable or partial remission (N=172) were randomized to 8 months of C-CT or fluoxetine with clinical management and assessed, free from protocol treatment, for 24 additional months. Pre-continuation-treatment characteristics that in survival analyses moderated treatments' effects on relapse over 8 months of continuation-phase treatment (residual symptoms and negative temperament) and on relapse/recurrence over the full observation period's 32 months (residual symptoms and age) were combined to estimate the potential advantage of C-CT versus fluoxetine for individual patients. Assigning patients to optimal continuation treatment (i.e., to C-CT or fluoxetine, depending on patients' pre-continuation-treatment characteristics) resulted in absolute reduction of relapse or recurrence risk by 16-21% compared to the other non-optimal treatment. Although these novel results require replication before clinical application, selecting optimal continuation treatment (i.e., personalizing treatment) for higher risk A-CT responders may decrease risks of MDD relapse and recurrence substantively.
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Affiliation(s)
- Jeffrey R. Vittengl
- Department of Psychology, Truman State University, Kirksville, MO, USA,Correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA, 1-660-785-6041, ; or, Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA, 1-214-648-5345.
| | - Lee Anna Clark
- Department of Psychology, University of Notre Dame, Notre Dame, IN, USA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robin B. Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA,Correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA, 1-660-785-6041, ; or, Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA, 1-214-648-5345.
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19
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Davey CG, Chanen AM. The unfulfilled promise of the antidepressant medications. Med J Aust 2017; 204:348-50. [PMID: 27169968 DOI: 10.5694/mja16.00194] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 03/17/2016] [Indexed: 11/17/2022]
Abstract
Australia has one of the highest rates of antidepressant use in the world; it has more than doubled since 2000, despite evidence showing that the effectiveness of these medications is lower than previously thought. An increasing placebo response rate is a key reason for falling effectiveness, with the gap between response to medications and placebo narrowing. Psychotherapies are effective treatments, but recent evidence from high-quality studies suggests that their effectiveness is also modest. Combined treatment with medication and psychotherapy provides greater effectiveness than either alone. The number of patients receiving psychotherapy had been declining, although this trend is probably reversing with the Medicare Better Access to Mental Health Care initiative. Antidepressant medications still have an important role in the treatment of moderate to severe depression; they should be provided as part of an overall treatment plan that includes psychotherapy and lifestyle strategies to improve diet and increase exercise. When medications are prescribed, they should be used in a way that maximises their chance of effectiveness.
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Affiliation(s)
- Christopher G Davey
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
| | - Andrew M Chanen
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
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20
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Rubio-Valera M, Peñarrubia-María MT, Fernández-Vergel R, Carvajal Tejadillo AC, Fernández Sánchez A, Aznar-Lou I, March-Pujol M, Serrano-Blanco A. [Impact of pharmaceutical intervention in preventing relapses in depression in Primary Care]. Aten Primaria 2015; 48:308-15. [PMID: 26415743 PMCID: PMC6877882 DOI: 10.1016/j.aprim.2015.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/21/2015] [Accepted: 05/25/2015] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To evaluate the long-term impact of a brief pharmacist intervention (PI) compared with usual care (UC) on prevention of depression relapse. DESIGN randomised controlled clinical trial SETTING Primary Care PARTICIPANTS Of the 179 depressed patients initiating antidepressants, the 113 whose clinical symptoms had remitted (main definition) at 6 months assessment were selected for this secondary study (PI=58; UC=55). INTERVENTION PI was an interview to promote medication adherence when patients get antidepressants from pharmacy. MAIN MEASUREMENTS Baseline, 3 months, and six-months follow-up assessments were made. The severity of depressive symptoms was evaluated with PHQ9. Patients presenting a remission of symptoms were selected. The patient medical records were reviewed to identify a relapse in the following 12 months by using 4 indicators. RESULTS There was a lower proportion of patients that relapsed in the PI group than in the UC group 18 months after initiation of treatment, but the difference was not statistically significant either in the intent-to-treat analysis (OR=0.734 [95%CI; 0.273-1.975]) or the per-protocol analysis (OR=0.615 [95%CI; 0.183 -2.060]). All the sensitivity analyses showed consistent results. The sample size and adherence to the protocol in the intervention group were low. CONCLUSION PI group showed a non-statistically significant tendency towards presenting fewer relapses. This could be related to the improvement in adherence among patients that received the intervention.
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Affiliation(s)
- María Rubio-Valera
- Unidad de investigación y desarrollo, Fundació Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España; Departamento de Prácticas Tuteladas, Facultad de Farmacia, Universidad de Barcelona, Barcelona, España; Grupo de Investigación Prisma, Red de Investigación Española en Actividades Preventivas y de Promoción de la Salud en Atención Primaria (RedIAPP), Barcelona, España
| | - M Teresa Peñarrubia-María
- Grupo de Investigación Prisma, Red de Investigación Española en Actividades Preventivas y de Promoción de la Salud en Atención Primaria (RedIAPP), Barcelona, España; Servicio de Atención Primaria Delta Llobregat, Centro de Atención Primaria Bartomeu Fabrés Anglada, Ámbito Costa Ponent, Institut Català de la Salut, Gavà, España.
| | - Rita Fernández-Vergel
- Grupo de Investigación Prisma, Red de Investigación Española en Actividades Preventivas y de Promoción de la Salud en Atención Primaria (RedIAPP), Barcelona, España; Servicio de Atención Primaria Delta Llobregat, Centro de Atención Primaria Bartomeu Fabrés Anglada, Ámbito Costa Ponent, Institut Català de la Salut, Gavà, España
| | - Andrea Cecilia Carvajal Tejadillo
- Servicio de Atención Primaria Delta Llobregat, Centro de Atención Primaria Bartomeu Fabrés Anglada, Ámbito Costa Ponent, Institut Català de la Salut, Gavà, España
| | - Ana Fernández Sánchez
- Grupo de Investigación Prisma, Red de Investigación Española en Actividades Preventivas y de Promoción de la Salud en Atención Primaria (RedIAPP), Barcelona, España; Observatorio de Investigación y Política, Facultad de Ciencias de la Salud, Universidad de Sydney, Sydney, Australia
| | - Ignacio Aznar-Lou
- Unidad de investigación y desarrollo, Fundació Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - Marian March-Pujol
- Departamento de Prácticas Tuteladas, Facultad de Farmacia, Universidad de Barcelona, Barcelona, España
| | - Antoni Serrano-Blanco
- Unidad de investigación y desarrollo, Fundació Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España; Grupo de Investigación Prisma, Red de Investigación Española en Actividades Preventivas y de Promoción de la Salud en Atención Primaria (RedIAPP), Barcelona, España
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Korgaonkar MS, Rekshan W, Gordon E, Rush AJ, Williams LM, Blasey C, Grieve SM. Magnetic Resonance Imaging Measures of Brain Structure to Predict Antidepressant Treatment Outcome in Major Depressive Disorder. EBioMedicine 2014; 2:37-45. [PMID: 26137532 PMCID: PMC4484820 DOI: 10.1016/j.ebiom.2014.12.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 11/30/2014] [Accepted: 12/01/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Less than 50% of patients with Major Depressive Disorder (MDD) reach symptomatic remission with their initial antidepressant medication (ADM). There are currently no objective measures with which to reliably predict which individuals will achieve remission to ADMs. METHODS 157 participants with MDD from the International Study to Predict Optimized Treatment in Depression (iSPOT-D) underwent baseline MRIs and completed eight weeks of treatment with escitalopram, sertraline or venlafaxine-ER. A score at week 8 of 7 or less on the 17 item Hamilton Rating Scale for Depression defined remission. Receiver Operator Characteristics (ROC) analysis using the first 50% participants was performed to define decision trees of baseline MRI volumetric and connectivity (fractional anisotropy) measures that differentiated non-remitters from remitters with maximal sensitivity and specificity. These decision trees were tested for replication in the remaining participants. FINDINGS Overall, 35% of all participants achieved remission. ROC analyses identified two decision trees that predicted a high probability of non-remission and that were replicated: 1. Left middle frontal volume < 14 · 8 mL & right angular gyrus volume > 6 · 3 mL identified 55% of non-remitters with 85% accuracy; and 2. Fractional anisotropy values in the left cingulum bundle < 0 · 63, right superior fronto-occipital fasciculus < 0 · 54 and right superior longitudinal fasciculus < 0 · 50 identified 15% of the non-remitters with 84% accuracy. All participants who met criteria for both decision trees were correctly identified as non-remitters. INTERPRETATION Pretreatment MRI measures seem to reliably identify a subset of patients who do not remit with a first step medication that includes one of these commonly used medications. Findings are consistent with a neuroanatomical basis for non-remission in depressed patients. FUNDING Brain Resource Ltd is the sponsor for the iSPOT-D study (NCT00693849).
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Affiliation(s)
- Mayuresh S Korgaonkar
- The Brain Dynamics Centre, Westmead Millennium Institute, Sydney Medical School, Sydney, NSW, Australia ; Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Westmead Hospital, Sydney, NSW, Australia
| | - William Rekshan
- Brain Resource Ltd, Sydney, NSW, Australia ; Brain Resource Ltd, San Francisco, CA, USA
| | - Evian Gordon
- The Brain Dynamics Centre, Westmead Millennium Institute, Sydney Medical School, Sydney, NSW, Australia ; Brain Resource Ltd, Sydney, NSW, Australia ; Brain Resource Ltd, San Francisco, CA, USA
| | - A John Rush
- Duke-National University of Singapore, Singapore
| | - Leanne M Williams
- The Brain Dynamics Centre, Westmead Millennium Institute, Sydney Medical School, Sydney, NSW, Australia ; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305, USA ; Sierra-Pacific Mental Illness Research, Education, Clinical Center (MIRECC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | | | - Stuart M Grieve
- The Brain Dynamics Centre, Westmead Millennium Institute, Sydney Medical School, Sydney, NSW, Australia ; Sydney Translational Imaging Laboratory, Charles Perkins Centre and Sydney Medical School, University of Sydney, NSW 2006, Australia ; Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW 2006, Australia
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Craighead WE, Dunlop BW. Combination Psychotherapy and Antidepressant Medication Treatment for Depression: For Whom, When, and How. Annu Rev Psychol 2014; 65:267-300. [DOI: 10.1146/annurev.psych.121208.131653] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- W. Edward Craighead
- Department of Psychiatry and Behavioral Sciences and
- Department of Psychology, Emory University, Atlanta, Georgia 30322; ,
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Shiovitz T, Greenberg WM, Chen C, Forero G, Gommoll CP. A Randomized, Double-blind, Placebo-controlled Trial of the Efficacy and Safety of Levomilnacipran ER 40-120mg/day for Prevention of Relapse in Patients with Major Depressive Disorder. INNOVATIONS IN CLINICAL NEUROSCIENCE 2014; 11:10-22. [PMID: 24653937 PMCID: PMC3960779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Major depressive disorder is often chronic, with relapse and recurrence common. Levomilnacipran extended-release is a potent and selective serotonin and reuptake inhibitor approved in the United States for treatment of major depressive disorder in adults. The objective of this study (NCT01085812) was to evaluate the efficacy, safety, and tolerability of levomilnacipran extended-release in the prevention of relapse in patients with major depressive disorder. DESIGN A 24-week Phase III randomized, double-blind, controlled trial comparing levomilnacipran extended-release 40-120mg/day with placebo for relapse prevention in patients with major depressive disorder who had responded to 12-week, open-label treatment with levomilnacipran extended-release. Statistical power was calculated on the assumption that 38 percent of placebo and 20 percent of levomilnacipran extended-release patients would relapse. SETTING Thirty-six outpatient study centers throughout the United States and Canada. PARTICIPANTS Of 348 patients who met randomization criteria and entered double-blind treatment, three discontinued prior to treatment, 112 were randomized to placebo, and 233 to levomilnacipran extended-release. PRIMARY OUTCOME Time to relapse was analyzed using the Cox proportional hazard-regression model with treatment group and baseline Montgomery-Åsberg Depression Rating Scale score as explanatory variables. Safety was also evaluated. RESULTS Time to relapse was longer for levomilnacipran extended-release versus placebo (hazard ratio [95% confidence interval] = 0.68 [0.40][1.17]), but the treatment difference was not statistically significant (P=0.165). A relatively low percentage of patients from either group relapsed (placebo=20.5%, levomilnacipran extended-release=13.9%). CONCLUSION This study did not detect between-treatment group differences, potentially due to lower than expected relapse rates in the placebo group. Levomilnacipran extended-release was generally well tolerated.
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Affiliation(s)
- Thomas Shiovitz
- Dr. Shiovitz with the California Neuroscience Research Medical Group Inc, Sherman Oaks, California; and Dr. Greenberg, Mr. Chen, Ms. Forero, and Mr. Gommoll are from Forest Research Institute, Jersey City, New Jersey
| | - William M Greenberg
- Dr. Shiovitz with the California Neuroscience Research Medical Group Inc, Sherman Oaks, California; and Dr. Greenberg, Mr. Chen, Ms. Forero, and Mr. Gommoll are from Forest Research Institute, Jersey City, New Jersey
| | - Changzheng Chen
- Dr. Shiovitz with the California Neuroscience Research Medical Group Inc, Sherman Oaks, California; and Dr. Greenberg, Mr. Chen, Ms. Forero, and Mr. Gommoll are from Forest Research Institute, Jersey City, New Jersey
| | - Giovanna Forero
- Dr. Shiovitz with the California Neuroscience Research Medical Group Inc, Sherman Oaks, California; and Dr. Greenberg, Mr. Chen, Ms. Forero, and Mr. Gommoll are from Forest Research Institute, Jersey City, New Jersey
| | - Carl P Gommoll
- Dr. Shiovitz with the California Neuroscience Research Medical Group Inc, Sherman Oaks, California; and Dr. Greenberg, Mr. Chen, Ms. Forero, and Mr. Gommoll are from Forest Research Institute, Jersey City, New Jersey
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Malhi GS, Hitching R, Berk M, Boyce P, Porter R, Fritz K. Pharmacological management of unipolar depression. Acta Psychiatr Scand Suppl 2013:6-23. [PMID: 23586873 DOI: 10.1111/acps.12122] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To be used in conjunction with 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of pharmacological treatments in depression derived from a literature review. METHOD Using our previous Clinical Practice Guidelines [Malhi et al. Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand 2009;119(Suppl. 439):27-46] as a foundation, these clinician guidelines target key practical considerations when prescribing pharmacotherapy. A comprehensive review of the literature was conducted using electronic database searches (PubMed, MEDLINE), and the findings have been synthesized and integrated alongside clinical experience. RESULTS The pharmacotherapy of depression is an iterative process that often results in partial and non-response. Beyond the initiation of antidepressants, the options within widely used strategies, such as combining agents and switching between agents, are difficult to prescribe because of the paucity of pertinent research. However, there is some evidence for second-line strategies, and a non-prescriptive algorithm can be derived that is based broadly on principles rather than specific steps. CONCLUSION Depression is by its very nature a heterogeneous illness that is consequently difficult to treat. Invariably, situation-specific factors often play a significant role and must be considered, especially in the case of partial and non-response. Consulting with colleagues and trialling alternate treatment paradigms are essential strategies in the management of depression.
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Affiliation(s)
| | | | | | - P. Boyce
- Discipline of Psychiatry; Sydney Medical School; University of Sydney; Sydney; NSW; Australia
| | - R. Porter
- Department of Psychological Medicine; University of Otago; Christchurch; New Zealand
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Ball SG, Desaiah D, Zhang Q, Thase ME, Perahia DGS. Efficacy and safety of duloxetine 60 mg once daily in major depressive disorder: a review with expert commentary. Drugs Context 2013; 2013:212245. [PMID: 24432034 PMCID: PMC3884746 DOI: 10.7573/dic.212245] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 08/21/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Major depressive disorder (MDD) is a significant public health concern and challenges health care providers to intervene with appropriate treatment. This article provides an overview of efficacy and safety information for duloxetine 60 mg/day in the treatment of MDD, including its effect on painful physical symptoms (PPS). DESIGN A literature search was conducted for articles and pooled analyses reporting information regarding the use of duloxetine 60 mg/day in placebo-controlled trials. SETTING Placebo-controlled, active-comparator, short- and long-term studies were reviewed. PARTICIPANTS Adult (≥18 years) patients with MDD. MEASUREMENTS Effect sizes for continuous outcome (change from baseline to endpoint) and categorical outcome (response and remission rates) were calculated using the primary measures of 17-item Hamilton Rating Scale for Depression (HAMD-17) or Montgomery-Åsberg Depression Rating Scale (MADRS) total score. The Brief Pain Inventory and Visual Analogue Scales were used to assess improvements in PPS. Glass estimation method was used to calculate effect sizes, and numbers needed to treat (NNT) were calculated based on HAMD-17 and MADRS total scores for remission and response rates. Safety data were examined via the incidence of treatment-emergent adverse events and by mean changes in vital-sign measures. RESULTS Treatment with duloxetine was associated with small-to-moderate effect sizes in the range of 0.12 to 0.72 for response rate and 0.07 to 0.65 for remission rate. NNTs were in the range of 3 to 16 for response and 3 to 29 for remission. Statistically significant improvements (p≤0.05) were observed in duloxetine-treated patients compared to placebo-treated patients in PPS and quality of life. The safety profile of the 60-mg dose was consistent with duloxetine labeling, with the most commonly observed significant adverse events being nausea, dry mouth, diarrhea, dizziness, constipation, fatigue, and decreased appetite. CONCLUSION These results reinforce the efficacy and tolerability of duloxetine 60 mg/day as an effective short- and long-term treatment for adults with MDD. The evidence of the independent analgesic effect of duloxetine 60 mg/day supports its use as a treatment for patients with PPS associated with depression. This review is limited by the fact that it included randomized clinical trials with different study designs. Furthermore, data from randomized controlled trials may not generalize well to real clinical practice.
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Affiliation(s)
- Susan G Ball
- Lilly Research Laboratory, Eli Lilly and Company, Indianapolis, IN, USA
| | - Durisala Desaiah
- Lilly Research Laboratory, Eli Lilly and Company, Indianapolis, IN, USA
| | - Qi Zhang
- Lilly Research Laboratory, Eli Lilly and Company, Indianapolis, IN, USA
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - David G S Perahia
- Lilly Research Centre, Windlesham, Surrey, UK; ; The Gordon Hospital, London, UK
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Weisler RH, Childress AC. Treating attention-deficit/hyperactivity disorder in adults: focus on once-daily medications. Prim Care Companion CNS Disord 2012; 13:11r01168. [PMID: 22454805 DOI: 10.4088/pcc.11r01168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 06/15/2011] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVE To review the efficacy, safety, and abuse liability of approved treatments in adults with attention-deficit/hyperactivity disorder (ADHD), with a focus on once-daily medications. DATA SOURCES PubMed was searched for relevant studies/reviews in English from 2002 to 2011 on adult ADHD treatments. STUDY SELECTION Keywords used in the search were ADHD, adults, and treatment. Limits included only clinical trials, meta-analyses, randomized controlled trials, and reviews including adults (aged ≥ 19 years). DATA EXTRACTION Selection criteria returned 471 publications. Retrieved studies were excluded if they primarily focused on children, treatments not indicated for ADHD, or ADHD and comorbid conditions. DATA SYNTHESIS An epidemiologic survey revealed that 10.9% of adults identified with ADHD had received treatment during the prior 12 months. Treatments for ADHD in adults include pharmacologic and nonpharmacologic options. US Food and Drug Administration-approved long-acting stimulants and a nonstimulant with proven efficacy and safety profiles have been developed and include osmotic-release oral system methylphenidate hydrochloride (OROS-methylphenidate), extended-release dexmethylphenidate hydrochloride, mixed amphetamine salts extended release (MAS-XR), the nonstimulant atomoxetine hydrochloride, and the prodrug lisdexamfetamine dimesylate. Long-acting stimulants differ in formulation characteristics used to achieve extended release, with OROS-methylphenidate employing an osmotic-release technology, extended-release dexmethylphenidate hydrochloride and MAS-XR using pH-dependent beads, and lisdexamfetamine dimesylate using prodrug technology. These features variably affect pharmacokinetic characteristics, duration of action, and abuse liability. While all long-acting medications have varied pharmacokinetic features, mechanism of action, and duration of effect, all are generally efficacious and safety profiles are similar. CONCLUSION Approved long-acting treatments in adults with ADHD were effective in improving symptoms and were generally well tolerated.
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Affiliation(s)
- Richard H Weisler
- Department of Psychiatry, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, and Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Dr Weisler); and Department of Family Practice, Center for Psychiatry and Behavioral Medicine, Inc, Las Vegas, Nevada, and Department of Psychiatry at the University of Nevada School of Medicine, Reno (Dr Childress)
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Gartlehner G, Thaler K, Hill S, Hansen RA. How should primary care doctors select which antidepressants to administer? Curr Psychiatry Rep 2012; 14:360-9. [PMID: 22648236 DOI: 10.1007/s11920-012-0283-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Clinicians can choose among various second-generation antidepressants for treating depressive disorders, such as major depressive disorder, subsyndromal depression, or dysthymia. Systematic reviews indicate that available drugs differ in frequency of administration, costs, and the risks of some adverse events but have similar efficacy for treating major depressive disorder. Furthermore, evidence does not support the choice of one antidepressant over another based on accompanying symptoms, such anxiety, insomnia, or pain. Available studies provide little guidance for clinicians about the benefits of second-generation antidepressants for treating dysthymia and subsyndromal depression. Evidence is also unclear about the comparative risks of serious adverse events, such as suicidality, seizures, fractures, increased bleeding, or serotonin syndrome. This article summarizes the best available evidence regarding comparative benefits and harms of second-generation antidepressants for treating depressive disorders.
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Affiliation(s)
- Gerald Gartlehner
- Department of Evidence-based Medicine and Clinical Epidemiology, Danube University, Karl Dorrek-Strasse 30, 3500, Krems, Austria.
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Dunlop BW, Holland P, Bao W, Ninan PT, Keller MB. Recovery and subsequent recurrence in patients with recurrent major depressive disorder. J Psychiatr Res 2012; 46:708-15. [PMID: 22475319 PMCID: PMC3677162 DOI: 10.1016/j.jpsychires.2012.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/16/2012] [Accepted: 03/01/2012] [Indexed: 10/28/2022]
Abstract
In contrast to "remission" from an episode of major depressive disorder (MDD), for which there is general agreement in the literature, the optimal definition of "recovery" from MDD is uncertain. Previous definitions of recovery have used inconsistent thresholds for symptom severity and duration of wellness. To address the effects of duration and degree of recovery from an episode of MDD on recurrence risk, and the impact of maintenance antidepressant treatment on recurrence, we analyzed 258 patients from a randomized, double-blind study of outpatients with recurrent MDD. All patients had responded to 8½ months of venlafaxine extended release and were subsequently randomized to receive venlafaxine ER or placebo during 2 consecutive 12-month maintenance phases. Four definitions of recovery were used to evaluate recovery rates and time to recurrence: (1) 17-item Hamilton Depression Rating Scale (HAM-D(17)) total score ≤3 with duration ≥120 days; (2) HAM-D(17) ≤3 with duration ≥56 days; (3) HAM-D(17) ≤7 with duration ≥120 days; and (4) HAM-D(17) ≤7 with duration ≥56 days. Recovery definitions using lower symptom severity and longer duration thresholds produced lower rates of recurrence. Patients on placebo were more likely to have a recurrence than patients on venlafaxine ER, with hazard ratio (HR) ranging from 2.5 among patients who recovered by the most relaxed criteria (definition 4), to 5.3 among patients who recovered by the most stringent criteria (definition 1). We conclude that protection against recurrence derives from the degree and duration of recovery, particularly for patients maintained on antidepressant medication.
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Affiliation(s)
- Boadie W. Dunlop
- Emory University School of Medicine, 1256 Briarcliff Road, Building A, 3rd Floor, Atlanta, GA 30322, USA,Corresponding author. Tel.: +1 404 727 8969; fax: +1 404 727 3700. (B.W. Dunlop)
| | - Peter Holland
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Rd # 287 Boca Raton, FL 33431, USA
| | - Weihang Bao
- Pfizer Inc, 500 Arcola Rd., Collegeville, PA 19426, USA
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Thombs BD, Ziegelstein RC. When prevention is a bad idea: problems with the DECARD trial and the premise behind it. J Psychosom Res 2012; 72:333-5. [PMID: 22469274 DOI: 10.1016/j.jpsychores.2012.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 02/18/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
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Abstract
Current systematic reviews yielded relatively small efficacy effect sizes of different psychopharmacological agents compared to placebo. It seems that these effect sizes have decreased compared to earlier meta-analyses. We speculate about factors explaining the decrease of effect size such as lower methodological requirements for earlier randomised controlled trials, but in particular enormous methodological problems of current trials such as chronic patient populations, exclusion of severely ill patients by the protocols, sponsoring by the pharmaceutical industry and so-called professional patients. A few examples from general medicine are used to illustrate that the effect sizes of other medications are often also surprisingly small. Psychotropic drugs are efficacious, but they need to be prudently applied according to evidence-based criteria.
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Abstract
Newer generation antidepressant drugs, with improvements in safety and tolerability, have replaced tricyclic antidepressants as first-line treatment of depressive illness. However, no single antidepressant drug from any class has distinguished itself as the obvious first-line treatment of major depression. The choice of therapy is driven primarily by patient choice, with informed consent for the risks of adverse effects. Cost has become an additional factor in this decision as several of the newer antidepressant drugs are now available in generic form. Several augmentation and drug-switching strategies have demonstrated benefit in refractory illness. While no single strategy distinguished itself as superior to the others, some have been more rigorously tested. Ongoing efforts at improving effectiveness, time to response, and tolerability have led to novel drug therapies. Efforts at characterizing predictors of treatment outcomes now include pharmacogenetic studies.
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Abstract
Prevention of the risk of recurrence of depressive episodes is a dynamic process that begins early in the management. Although complete remission is obtained for almost half of the treated depressive episodes, a heuristic conceptual thinking apprehends depression as a potentially chronic disorder when considering relapse and recurrence prevention. Multiple actions of care have to be initiated. They are formalised, but also adjustable to the needs of a critical management period throughout the follow-up. These actions include the prescription of an antidepressant at an effective dosage. They also consider the preventative and therapeutic impact of psychotherapy. The search for residual symptoms of depression is the rule, and addition of other medication should be considered if needed. These recommendations are evidence-based in the context of recurrence prevention. Nevertheless, many other initiatives are equally important recommendations in terms of therapeutic impact. Thus, rigorous evaluation of the initial symptomatology, promotion of information on disease, health-care advices, as well as implementation of family and other networks are good-practices. Such actions should be conducted in a relationship based on a therapeutic alliance. These elements need to be adjusted and contextualised in line with the Health System, mode of medical practice and unique style of the therapist. Proactive and sustainable implementations of these guidelines are required in the context of a unique and open therapeutic relationship for both therapist and patient.
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Blumenthal JA. New frontiers in cardiovascular behavioral medicine: comparative effectiveness of exercise and medication in treating depression. Cleve Clin J Med 2011; 78 Suppl 1:S35-43. [PMID: 21972328 PMCID: PMC3749736 DOI: 10.3949/ccjm.78.s1.06] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Exercise, considered a mainstay of cardiac rehabilitation, has been shown to reduce cardiac risk factors such as hyperlipidemia and hypertension. Growing evidence also suggests that exercise has beneficial effects on mental health, which is relevant for cardiac patients because of the prognostic significance of depression in patients with coronary heart disease (CHD). Depression has been associated with increased mortality and nonfatal cardiac events in patients with CHD; it is also associated with worse outcomes in patients who undergo coronary artery bypass graft surgery and those who have heart failure. The standard therapy for depression is pharmacologic treatment, often with second-generation antidepressants such as selective serotonin reuptake inhibitors. Despite their widespread use, antidepressants have only modest effects on depression for many patients compared with placebo controls. Exercise therapy, already an established component of cardiac rehabilitation, has potential efficacy as a treatment for depression in cardiac disease patients. Randomized controlled trials are needed to determine the clinical effects of exercise in this population and to compare the effects of exercise with those of antidepressants.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA.
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Cipriani A, Barbui C, Butler R, Hatcher S, Geddes J. Depression in adults: drug and physical treatments. BMJ CLINICAL EVIDENCE 2011; 2011:1003. [PMID: 21609510 PMCID: PMC3217759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Depression may affect up to 10% of the population, with half of affected people having recurrence of their symptoms. In mild to moderate depression, there is no reliable evidence that any one treatment is superior in improving symptoms of depression, but the strength of evidence supporting different treatments varies. In severe depression, only prescription antidepressants and electroconvulsive therapy are known to improve symptoms. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in mild to moderate and severe depression, and in treatment-resistant depression? Which interventions reduce relapse rates? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 88 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antidepressant drugs (tricyclic antidepressants [including low-dose tricyclic antidepressants], selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or venlafaxine), continuing prescription antidepressant drugs, electroconvulsive therapy, exercise, lithium augmentation, pindolol augmentation, and St John's wort.
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Affiliation(s)
- Andrea Cipriani
- Department of Public Health and Community Medicine, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
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Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med 2011; 6:8. [PMID: 21569244 PMCID: PMC3123637 DOI: 10.1186/1747-5341-6-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 05/10/2011] [Indexed: 05/12/2023] Open
Abstract
We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% greater than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy. Our most important criticism is Ioannidis' basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found. We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary.
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Affiliation(s)
- John M Davis
- Gilman Professor of Psychiatry, Psychiatric Institute, Department of Psychiatry, University of Illinois at Chicago and University of Maryland Psychiatric Research Center, Chicago, IL, and Baltimore, MD, USA. 1601 W. Taylor Street, 508W, Chicago, IL, USA
| | - William J Giakas
- Rockford Psychiatric Medical Services, S.C., Rockford, IL 61107 USA
| | - Jie Qu
- Department of Psychology-Neuroscience Track, Yale University, New Haven, CT, USA
| | - Pavan Prasad
- Psychiatric Institute, Department of Psychiatry, University of Illinois at Chicago USA
| | - Stefan Leucht
- Klinik fur Psychiatrie und Psychotherapie der TU-Munchen. Ismaningerstr. 22, 81675 Munchen, Germany
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Continuing treatment of depression in the elderly: a systematic review and meta-analysis of double-blinded randomized controlled trials with antidepressants. Am J Geriatr Psychiatry 2011; 19:249-55. [PMID: 21425505 DOI: 10.1097/jgp.0b013e3181ec8085] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To establish the efficacy and tolerability of continuing treatment with antidepressants in preventing relapses and recurrences in elderly depressed patients and to analyze differences between tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). DESIGN The authors conducted a systematic literature search to identify all randomized, placebo-controlled, double-blinded clinical trials(RCTs) in elderly patients. Data were pooled from eight double-blinded RCTs of continuation and maintenance treatment in the elderly with 925 participating patients. RESULTS The number of patients needed to treat (NNT) for antidepressants to prevent one additional relapse or recurrence was 3 6 (95% confidence interval [CI]: 2.8-4.8).The NNT for TCAs was 2.9 (95% CI: 2.2-4.6), compared with a NNT for SSRIs of 4.2(95% CI: 3.2-5.9). In the five studies that provide drop out data, 14 of 330 patients(4.2%) using an antidepressant dropped out due to side effects compared with 17 of 330 patients (5.2%) using a placebo (χ² = 0.305, df = 1, p = 0.581). Tolerability did not differ between TCAs and SSRIs. CONCLUSION Continuing treatment with antidepressants in elderly patients is efficacious compared with placebo in preventing relapses and recurrences. Efficacy and tolerability during long-term treatment does not differ between TCAs and SSRIs.
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Pae CU, Forbes A, Patkar AA. Aripiprazole as adjunctive therapy for patients with major depressive disorder: overview and implications of clinical trial data. CNS Drugs 2011; 25:109-27. [PMID: 21254788 DOI: 10.2165/11538980-000000000-00000] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aripiprazole was initially approved to treat schizophrenia and later approved for bipolar mania, as a monotherapy and an adjunctive therapy (manic or mixed episodes), and for irritability associated with autism. Aripiprazole is a partial agonist at dopamine D(2) and D(3) and serotonin 5-HT(1A) receptors, and is an antagonist at 5-HT(2A) receptors. This profile, and convincing preliminary data from small-scale studies, provided the rationale for the large-scale exploration of aripiprazole for unipolar depression. Recently, three 6-week, large-scale, randomized, double-blind, placebo-controlled clinical trials demonstrated clinically meaningful efficacy for aripiprazole as an adjunctive therapy to antidepressants for treating major depressive disorder (MDD). In November 2007, aripiprazole was approved by the US FDA as an adjunctive therapy to antidepressants for treating MDD, with support from two of the above-mentioned trials. In the trials, aripiprazole was demonstrated to be safe and well tolerated, and showed a minimal trend for weight gain over the course of a 6-week treatment. The incidence of akathisia was higher than that reported in studies of patients with schizophrenia; however, most cases were mild to moderate and infrequently lead to discontinuation (5/1090 from all three trials). This comprehensive review provides an overview of the data from all three 6-week studies (including a pooled analysis) and from an unpublished 52-week, open-label extension study, to inform physicians and facilitate reasonable treatment decisions. In addition, specific issues associated with the use of aripiprazole as an adjunctive therapy in patients with MDD, including possible early treatment effect, appropriate timing of therapy initiation, appropriate dosing and duration of treatment, possible differential effect on depressive subgroups and long-term tolerability, are also discussed.
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Affiliation(s)
- Chi-Un Pae
- Department of Psychiatry, Bucheon St. Marys Hospital, The Catholic University of Korea College of Medicine, Bucheon, Kyounggi-Do, Republic of Korea.
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Wang JT, Hoffman B, Blumenthal JA. Management of depression in patients with coronary heart disease: association, mechanisms, and treatment implications for depressed cardiac patients. Expert Opin Pharmacother 2011; 12:85-98. [PMID: 20715885 PMCID: PMC2997888 DOI: 10.1517/14656566.2010.513701] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE OF THE FIELD Coronary heart disease (CHD) and depression are two leading causes of death and disability in the United States and worldwide. Depression is especially common in cardiac patients, and there is growing evidence that depression is a risk factor for fatal and nonfatal events in CHD patients. AREAS COVERED IN THIS REVIEW This paper reviews current literature of depression as a risk factor for CHD along with pharmacologic and non-pharmacologic treatments for depression in cardiac patients. WHAT THE READER WILL GAIN Readers will gain knowledge about the importance of depression as a CHD risk factor and learn the results of efforts to treat depressed CHD patients. TAKE HOME MESSAGE Although randomized clinical trials (RCTs) of medication and non-pharmacologic therapies have not demonstrated that treating depression improves survival, there is evidence that treating depressed patients can reduce depressive symptoms and improve quality of life. Additional RCTs are needed, including evaluation of non-pharmacologic therapies such as exercise, to examine the effects of treatment of depression on medical and psychosocial outcomes.
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Affiliation(s)
- Jenny T Wang
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Box 3119, Durham, NC 27710, USA
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Brunoni AR, Fraguas R, Fregni F. Pharmacological and combined interventions for the acute depressive episode: focus on efficacy and tolerability. Ther Clin Risk Manag 2009; 5:897-910. [PMID: 19956554 PMCID: PMC2781064 DOI: 10.2147/tcrm.s5751] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Use of antidepressants is the gold standard therapy for major depression. However, despite the large number of commercially available antidepressant drugs there are several differences among them in efficacy, tolerability, and cost-effectiveness. In addition the optimal augmentation strategy is still not clear when dealing with treatment-resistant depression, a condition that affects 15% to 40% of depressed patients. METHODS We therefore reviewed the main characteristics of these drugs regarding their efficacy, tolerability, side effects and cost-effectiveness, by accessing all meta-analyses and systematic reviews published from 2004 to 2009. In addition, we reviewed the augmentation strategy of associated antidepressants with neurostimulation therapies (such as transcranial magnetic stimulation [TMS] and transcranial direct current stimulation [tDCS]). A search was undertaken in MEDLINE, Web of Science, Cochrane, and Scielo databases. We included: 21 meta-analyses of antidepressant trials, 15 neurostimulation clinical trials and 8 studies of pharmacoeconomics. We then performed a comprehensive review on these articles. RESULTS AND CONCLUSION Although recent meta-analyses suggest sertraline and escitalopram might have increased efficacy/tolerability, other studies and large pragmatic trials have not found these to be superior to other antidepressant drugs. Also, we did not identify any superior drug in terms of cost-effectiveness due to the different designs observed among pharmacoecomics studies. Side effects such as sexual dysfunction, gastrointestinal problems and weight gain were common causes of discontinuation. Tolerability was an important issue for novel neurostimulation interventions, such as TMS and tDCS. These therapies might be interesting augmentation strategies, considering their benign profile of side effects, if proper safety parameters are adopted.
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Affiliation(s)
- Andre R Brunoni
- Department and Institute of Psychiatry, University of Sao Paulo, Brazil
| | - Renerio Fraguas
- Department and Institute of Psychiatry, University of Sao Paulo, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation, Spaulding Rehabilitation Center, Harvard Medical School and Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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Lam RW, Kennedy SH, Grigoriadis S, McIntyre RS, Milev R, Ramasubbu R, Parikh SV, Patten SB, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disord 2009; 117 Suppl 1:S26-43. [PMID: 19674794 DOI: 10.1016/j.jad.2009.06.041] [Citation(s) in RCA: 284] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 06/23/2009] [Indexed: 01/16/2023]
Abstract
BACKGROUND In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. METHODS The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included Levels of Evidence and expert clinical support. This section on "Pharmacotherapy" is one of 5 guideline articles. RESULTS Despite emerging data on efficacy and tolerability differences amongst newer antidepressants, variability in patient response precludes identification of specific first choice medications for all patients. All second-generation antidepressants have Level 1 evidence to support efficacy and tolerability and most are considered first-line treatments for MDD. First-generation tricyclic and monoamine oxidase inhibitor antidepressants are not the focus of these guidelines but generally are considered second- or third-line treatments. For inadequate or incomplete response, there is Level 1 evidence for switching strategies and for add-on strategies including lithium and atypical antipsychotics. LIMITATIONS Most of the evidence is based on trials for registration and may not reflect real-world effectiveness. CONCLUSIONS Second-generation antidepressants are safe, effective and well tolerated treatments for MDD in adults. Evidence-based switching and add-on strategies can be used to optimize response in MDD that is inadequately responsive to monotherapy.
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