How well do elderly patients with major depressive disorder respond to antidepressants: a systematic review and single-group meta-analysis

Subjective and objective cognitive functioning in untreated late-life depression: An exploration centered on comorbid generalized anxiety disorder

BACKGROUND

Late-Life Depression (LLD) is a prevalent mental health disorder that is often accompanied by cognitive impairments. The objective of this study is to investigate the influence of coexisting Generalized Anxiety Disorder (GAD) on both subjective and objective cognitive abilities in untreated LLD individuals.

METHODS

A total of 77 participants aged 60 years and above were recruited for this study, comprising 31 individuals with Major Depressive Disorder (LLD group), 46 with MDD and coexisting Generalized Anxiety Disorder (LLDA group), and 54 healthy controls (HC). Prior to the study, all patients had abstained from psychotropic medication for a minimum of two weeks. Comprehensive neuropsychological assessments were administered to all participants.

RESULTS

The LLDA group exhibited substantial disparities in memory, attention, processing speed,executive function,overall cognitive functioning, and subjective cognitive functioning when compared to the HC group. The LLD group displayed deficits in memory, SCWT-W in attention, SCWT-C in processing speed,overall cognitive functioning, and subjective cognitive functioning in comparison to the healthy controls. Although the LLD group achieved lower average scores in executive function, TMTA in processing speed, and DSST in attention than the HC group, no significant distinctions were identified between these groups in these domains. Linear regression analysis unveiled that anxiety symptoms had a significant impact on subjective cognitive deficits among MDD patients, but exhibited a milder influence on objective cognitive performance. After adjusting for the severity of depression, anxiety symptoms were found to affect TMTA in processing speed and subjective cognitive functioning in LLD patients.

CONCLUSION

Late-Life Depression (LLD) exhibits pervasive cognitive impairments, particularly in individuals with generalized anxiety disorder, presenting a crucial target for future therapeutic interventions. Among elderly individuals with depression, anxiety symptoms significantly impact subjective cognitive functioning, suggesting its potential utility in distinguishing between depression-associated cognitive decline and pre-dementia conditions.

A narrative review: suicide and suicidal behaviour in older adults

Globally, suicide is a public health concern that claims the lives of many each year. The complex etiology and factors contributing to the risk of suicide make it hard to predict the likelihood of death by suicide. Suicide rates have been increasing over the past 25 years in patients aged 65 years and older, and with the expected increases in the size of the older adult population and the under-detection of suicide risk, these rates may continue to increase. To mitigate and attempt to limit this expected increase, it is important to understand the risk and protective factors of suicide in older adults. This narrative review focuses on individuals above the age of 65 and encompasses relevant peer-reviewed publications from the past 25 years to cover fatal and non-fatal suicidal behaviour. It summarizes several important risk factors for suicide and suicidal behaviors while considering how risk can be detected, assessed, prevented, and mitigated. Screening methods to detect suicide and depression in older adults were examined based on their effectiveness and suitability for use in this population. Lastly, the impacts of the COVID-19 pandemic on suicide rates in older adults were described.

Safety and tolerance of combination of monoamine oxidase inhibitors and direct dopamine agonists in adults and older adults with highly resistant depression

INTRODUCTION

Dopamine (DA) is likely to be involved in some depressive dimensions, such as anhedonia and amotivation, which account for a part of treatment-resistant forms. Monoamine oxidase inhibitors (MAOI) and direct D2 and D3 receptors agonists (D2/3r-dAG) are known to help, but we lack safety data about their combined usage. We report on safety and tolerance of the MAOI+D2r-dAG combination in a clinical series.

METHOD

All patients referred to our recourse center for depression between 2013 and 2021 were screened to select those who did receive the combo. Data were extracted from clinical files.

RESULTS

Sixteen patients of 60±17 years of age (8 women, 7 with age>65years, all suffered from treatment resistant depression, 7 with bipolar disorder) received the combo. There were no life-threatening adverse effects (AE). However, AE were reported by 14 patients (88%) most of which were mild and consisted of insomnia, nausea, nervousness, confusion, impulse control disorder and/or "sleep attacks". One patient presented a serious AE requiring a short hospitalization for confusion. Intolerance led to failure to introduce treatment in two patients (13%). The retrospective non-interventional design, the variety of molecules, and the modest sample size limited the scope of these results.

CONCLUSION

There was no life-threatening safety issue in combining MAOI and D2/3r-dAG, especially regarding cardiovascular side effects. The systematic screening of AE might account for their frequency, but these precluded the treatment in only two patients. Comparative studies are needed to assess the efficacy of this new combination.

Antidepressants available in Japan for older people with major depressive disorder: A systematic review and meta-analysis

AIM

To update the major depressive disorder (MDD) treatment guidelines of the Japanese Society of Mood Disorders, we conducted a systematic review and pairwise meta-analysis of double-blind, randomized, placebo-controlled trials of available antidepressants in Japan for older adults with MDD.

METHODS

Outcome measures included response rate (primary), improvement in depressive symptom scale score, remission rate, all-cause discontinuation, discontinuation due to adverse events, and at least one adverse event. A random-effects model was used to calculate the risk ratio (RR) and standardized mean difference (SMD) with a 95% confidence interval (95% CI).

RESULTS

Nine double-blind, randomized, placebo-controlled trials (n = 2145) were identified. No study has been conducted in Japan. Our meta-analysis included the following antidepressants: duloxetine, escitalopram, imipramine, sertraline, venlafaxine, and vortioxetine. Antidepressants have significantly higher response rates than placebo (RR [95% CI] = 1.38 [1.04, 1.83], p = 0.02). Antidepressants outperformed placebo in terms of improving depressive symptom scale score (SMD [95% CI] = -0.62 [-0.92, -0.33], p < 0.0001). However, antidepressants were associated with a higher discontinuation rate due to adverse events (RR [95% CI] = 1.94 [1.30, 2.88], p = 0.001) and a higher incidence of at least one adverse event (RR [95% CI] = 1.11 [1.02, 1.21], p = 0.02) compared to placebo. The groups did not differ significantly in terms of remission rate or all-cause discontinuation.

CONCLUSIONS

Our meta-analysis concluded that treatment with antidepressants available in Japan is only weakly recommended for moderate to severe MDD in older adults.

Improving Traumatic Stress with Justice-Impacted Women and Women Experiencing Homelessness: A Pilot Study of Narrative Exposure Therapy

OBJECTIVE

We sought to investigate the feasibility, acceptability, and impact of a brief, manualized trauma-focused intervention aimed at improving PTSD symptoms in persons with complex PTSD, Narrative Exposure Therapy (NET).

DESIGN

Using a mixed methods approach, we tested the feasibility, acceptability, and impact of NET in a sample of trauma-affected women in traumatogenic circumstances: justice-impacted women in prison and women experiencing homelessness in a shelter. We quantitatively assessed data using a single sample, pre-/post-intervention design. We qualitatively assessed self-described symptom change and opportunities for intervention adaptation using a content analysis approach.

METHODS

Sixteen trauma-affected participants completed the intervention protocol. NET interventionists included one nurse practitioner, one registered nurse, and one nursing student. All NET participants attended pre-/post-intervention visits and active NET sessions. In-depth interviews were conducted at pre- and post-intervention, alongside a diagnostic battery.

RESULTS

NET was both highly feasible and acceptable among participants. Participants significantly improved on the intervention-specific outcome of PTSD symptoms, as well as somatic symptom burden, with large effect sizes. Participants also improved on subjective self-described symptom change. Participants offered recommendations regarding opportunities to enhance population-specific intervention acceptability.

CONCLUSIONS

Results from this pilot study are consistent with previous evidence demonstrating that NET facilitates improvements in women with traumatic stress. Findings of high feasibility, acceptability, and impact supports the use of NET in JW and WEH. Integrating participant recommendations to optimize acceptability may further support scalability and reach of NET. Replication with a larger sample and within a randomized controlled design is required to definitively determine effectiveness.

Pharmacological and Non-Pharmacological Treatments for Depression in Parkinson's Disease: An Updated Review

Depression represents one of the most common non-motor disorders in Parkinson's disease (PD) and it has been related to worse life quality, higher levels of disability, and cognitive impairment, thereby majorly affecting not only the patients but also their caregivers. Available pharmacological therapeutic options for depression in PD mainly include selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and tricyclic antidepressants; meanwhile, agents acting on dopaminergic pathways used for motor symptoms, such as levodopa, dopaminergic agonists, and monoamine oxidase B (MAO-B) inhibitors, may also provide beneficial antidepressant effects. Recently, there is a growing interest in non-pharmacological interventions, including cognitive behavioral therapy; physical exercise, including dance and mind-body exercises, such as yoga, tai chi, and qigong; acupuncture; therapeutic massage; music therapy; active therapy; repetitive transcranial magnetic stimulation (rTMS); and electroconvulsive therapy (ECT) for refractory cases. However, the optimal treatment approach for PD depression is uncertain, its management may be challenging, and definite guidelines are also lacking. It is still unclear which of these interventions is the most appropriate and for which PD stage under which circumstances. Herein, we aim to provide an updated comprehensive review of both pharmacological and non-pharmacological treatments for depression in PD, focusing on recent clinical trials, systematic reviews, and meta-analyses. Finally, we discuss the pharmacological agents that are currently under investigation at a clinical level, as well as future approaches based on the pathophysiological mechanisms underlying the onset of depression in PD.

Effectiveness of the Program to Encourage Active, Rewarding Lives (PEARLS) to reduce depression: a multi-state evaluation

Introduction

An estimated 15% of community-dwelling older adults have depressive symptoms in the U.S. The Program to Encourage Active, Rewarding Lives (PEARLS) is an evidence-based program for managing late-life depression. PEARLS is a home/community-based collaborative care model delivered by community-based organizations to improve access to quality depression care. Trained staff actively screen for depression to improve recognition, teach problem-solving and activity planning skills for self-management, and connect participants to other supports and services as needed.

Methods

This study examined 2015-2021 data from 1,155 PEARLS participants across four states to assess PEARLS effectiveness to reduce depressive symptoms. The clinical outcomes were measured by the self-reported PHQ-9 instrument to assess changes in depressive symptoms scored as depression-related severity, clinical remission, and clinical response. A generalized estimating equation (GEE) model was fitted to examine changes in composite PHQ-9 scores from baseline to the final session. The model adjusted for participants' age, gender, race/ethnicity, education level, income level, marital status, number of chronic conditions, and number of PEARLS sessions attended. Cox proportional hazards regression models were conducted to estimate the hazard ratio for improvement of depressive symptoms (i.e., remission or response), while adjusting for the covariates.

Results

PHQ-9 scale scores significantly improved from baseline to their final sessions (mean difference = -5.67, SEM = 0.16, p < 0.001). About 35% of participants achieved remission with PHQ-9 score < 5. Compared to participants with mild depression, patients with moderate depression (HR = 0.43, 95%CI = 0.35-0.55), moderately severe depression (HR = 0.28, 95%CI = 0.21-0.38), and severe depression (HR = 0.22 95%CI = 0.14-0.34) were less likely to experience clinical remission with PHQ-9 score < 5, while adjusting for the covariates. About 73% achieved remission based on no longer having one or both cardinal symptoms. Compared to participants with mild depression, patients with moderate depression (HR = 0.66, 95%CI = 0.56-0.78), moderately severe depression (HR = 0.46, 95%CI = 0.38-0.56), and severe depression (HR = 0.38, 95%CI = 0.29-0.51) were less likely to experience clinical remission, while adjusting for the covariates. Nearly 49% of participants had a clinical response or a ≥ 50% decrease in PHQ-9 scores over time. There were no differences between the severity of depression groups based on the time to clinical response.

Discussion

Findings confirm that PEARLS is an effective program to improve depressive symptoms among older adults in diverse real-world community settings and can be a more accessible option for depressive older adults who are traditionally underserved by clinical care.

Effects on Sleep Quality of Physical Exercise Programs in Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Given the beneficial effects of exercise in different populations and the close relationship between healthy ageing and sleep quality, our objective was to determine if physical exercise delivered through a structured program improves sleep quality in older adults.

METHODS

Embase, PubMed/MEDLINE, Web of Science, and Cochrane Register of Clinical Trials (CENTRAL) were searched to 15 January 2023. Studies that applied physical exercise programs in older adults were reviewed. Two independent reviewers analysed the studies, extracted the data, and assessed the quality of evidence.

RESULTS

Of the 2599 reports returned by the initial search, 13 articles reporting on 2612 patients were included in the data synthesis. The articles used interventions based on yoga (n = 5), multicomponent exercise (n = 3), walking (n = 2), cycling (n = 1), pilates (n = 1), elastic bands (n = 1), and healthy beat acupunch (n = 1). In the intervention group, we found significant improvement in Pittsburgh sleep quality index of -2.49 points (95% CI -3.84 to -1.14) in comparison to the control group (p = 0.0003) and sleep efficiency measured with objective instruments (MD 1.18%, 95% CI 0.86 to 1.50%, p < 0.0001).

CONCLUSION

Our results found that physical exercise programs in older adults improve sleep quality and efficiency measured with objective instruments.

Discontinuation of Antidepressants in Older Adults: A Literature Review

Polypharmacy increases the risk of unbearable side effects, drug-drug interactions, and hospitalizations in geriatric patients. The iatrogenic risk of inadequate management of antidepressants is very important in this population. Therefore, primary care physicians and geriatricians have the responsibility of the optimization of antidepressants prescriptions. Our work is a literature review of the European and the international guidelines regarding the management of antidepressants. We reviewed the PubMed database and Google scholar for articles and reviews from 2015. We also screened relevant articles for more references and searched the web for available European guidelines relevant to our topic. We divided our findings into four main inquiries that are Indication, effectiveness, tolerability, and iatrogenic risks. Poor or absence of effectiveness should lead to a readjustment of the treatment plan. In case of unbearable side effects, antidepressants should be stopped, and alternative non-pharmacological therapies should be proposed. Doctors should look out for drug-drug interaction risks in this population and constantly adjust the prescription. Prescription of antidepressants is not always evidence based which leads to heavy iatrogenic consequences. We suggest a simple 4-questions-algorithm that aims to remind doctors of the basics of good practice and helps in the process of deprescribing an antidepressant in older adults.

Depression After Parkinson's Disease: Treated Differently or Not At All?

Depression is a common, potentially debilitating non-motor symptom of Parkinson's disease which may manifest at any time and can respond to treatment. Although depression is a known primary mediator of health-related quality of life, it is currently unknown whether the timing of depression diagnosis relative to PD diagnosis affects receipt of depression treatment. Electronic health record data were examined to explore differences in depression treatment among patients diagnosed with depression before or after PD diagnosis. Compared to PD patients diagnosed with depression prior to PD, those diagnosed with depression following PD are less likely to receive any treatment, either pharmacologic or non-pharmacologic, indicating a temporal association between the time of PD diagnosis and receipt of depression treatment. This highlights a potentially substantial treatment gap, despite the existence of efficacious treatment. Diagnosis with PD appears to alter depression treatment and further research is warranted to determine potential causes and effective interventions.

Late-life depression: Epidemiology, phenotype, pathogenesis and treatment before and during the COVID-19 pandemic

Late-life depression (LLD) is one of the most common mental disorders among the older adults. Population aging, social stress, and the COVID-19 pandemic have significantly affected the emotional health of older adults, resulting in a worldwide prevalence of LLD. The clinical phenotypes between LLD and adult depression differ in terms of symptoms, comorbid physical diseases, and coexisting cognitive impairments. Many pathological factors such as the imbalance of neurotransmitters, a decrease in neurotrophic factors, an increase in β-amyloid production, dysregulation of the hypothalamic-pituitary-adrenal axis, and changes in the gut microbiota, are allegedly associated with the onset of LLD. However, the exact pathogenic mechanism underlying LLD remains unclear. Traditional selective serotonin reuptake inhibitor therapy results in poor responsiveness and side effects during LLD treatment. Neuromodulation therapies and complementary and integrative therapies have been proven safe and effective for the treatment of LLD. Importantly, during the COVID-19 pandemic, modern digital health intervention technologies, including socially assistive robots and app-based interventions, have proven to be advantageous in providing personal services to patients with LLD.

The association of change in peak oxygen uptake with use of psychotropics in community-dwelling older adults - The Generation 100 study

BACKGROUND

The use of psychotropics is high among the older population and may have detrimental effects on their physical and mental health. Cardiorespiratory fitness (CRF) is a strong and modifiable measure of health and declines with age. We aimed to study the association of change in CRF with use of psychotropics in community-dwelling older adults.

METHODS

We analyzed longitudinal data from 1531 older adults from the Generation 100 study, aged 70-77 years at inclusion, and with a permanent address in Trondheim, Norway. Data on objectively measured peak oxygen uptake (VO_2peak) were linked with register data from the Norwegian Prescription Database on prescribed psychotropics. The included psychotropics were antidepressants (N06A), antipsychotics (N05A), anxiolytics (N05B), hypnotics and sedatives (N05C), and N03AE (benzodiazepine derivatives). Analyses were done on any psychotropics as one group, and on the following separate groups: antidepressants (N06A), benzodiazepines (N05BA, N05CD, and N03AE), and z-hypnotics (N05CF). Peak oxygen uptake was measured four times over a five-year period and corresponding medication use was measured as defined daily doses (DDD). A random effects estimator was applied to investigate the association of change in VO_2peak with the use of psychotropics.

RESULTS

We found a statistically significant curvilinear association of change in VO_2peak with use of any psychotropics and antidepressants. For VO_2peak up to ~ 40 ml/kg/min, each 1 ml/kg/min increase was associated by a 3.3 DDD and 2.5 DDD decrease in use of any psychotropics and antidepressants, respectively. A bottoming-out effect was found and increases in VO_2peak above ~ 40 ml/kg/min showed increased use of any psychotropics and antidepressants. However, the association of change in VO_2peak with use was stronger for changes in the lower continuum of VO_2peak levels and decreased with increasing VO_2peak. No statistically significant association of change in VO_2peak with use of benzodiazepines and z-hypnotics were found. However, because of a non-randomized design, we cannot rule out the possibility of confounding by indication.

CONCLUSIONS

The results of this study show a curvilinear association of change in VO_2peak with use of any psychotropics and antidepressants in older adults. This relationship adds a new viewpoint on the adverse effects of psychotropic use and should be considered in interventions and policies aimed at reducing psychotropic medication use among the older population.

Characterizing Heterogeneity in Neuroimaging, Cognition, Clinical Symptoms, and Genetics Among Patients With Late-Life Depression

Importance

Late-life depression (LLD) is characterized by considerable heterogeneity in clinical manifestation. Unraveling such heterogeneity might aid in elucidating etiological mechanisms and support precision and individualized medicine.

Objective

To cross-sectionally and longitudinally delineate disease-related heterogeneity in LLD associated with neuroanatomy, cognitive functioning, clinical symptoms, and genetic profiles.

Design, Setting, and Participants

The Imaging-Based Coordinate System for Aging and Neurodegenerative Diseases (iSTAGING) study is an international multicenter consortium investigating brain aging in pooled and harmonized data from 13 studies with more than 35 000 participants, including a subset of individuals with major depressive disorder. Multimodal data from a multicenter sample (N = 996), including neuroimaging, neurocognitive assessments, and genetics, were analyzed in this study. A semisupervised clustering method (heterogeneity through discriminative analysis) was applied to regional gray matter (GM) brain volumes to derive dimensional representations. Data were collected from July 2017 to July 2020 and analyzed from July 2020 to December 2021.

Main Outcomes and Measures

Two dimensions were identified to delineate LLD-associated heterogeneity in voxelwise GM maps, white matter (WM) fractional anisotropy, neurocognitive functioning, clinical phenotype, and genetics.

Results

A total of 501 participants with LLD (mean [SD] age, 67.39 [5.56] years; 332 women) and 495 healthy control individuals (mean [SD] age, 66.53 [5.16] years; 333 women) were included. Patients in dimension 1 demonstrated relatively preserved brain anatomy without WM disruptions relative to healthy control individuals. In contrast, patients in dimension 2 showed widespread brain atrophy and WM integrity disruptions, along with cognitive impairment and higher depression severity. Moreover, 1 de novo independent genetic variant (rs13120336; chromosome: 4, 186387714; minor allele, G) was significantly associated with dimension 1 (odds ratio, 2.35; SE, 0.15; P = 3.14 ×108) but not with dimension 2. The 2 dimensions demonstrated significant single-nucleotide variant-based heritability of 18% to 27% within the general population (N = 12 518 in UK Biobank). In a subset of individuals having longitudinal measurements, those in dimension 2 experienced a more rapid longitudinal change in GM and brain age (Cohen f2 = 0.03; P = .02) and were more likely to progress to Alzheimer disease (Cohen f2 = 0.03; P = .03) compared with those in dimension 1 (N = 1431 participants and 7224 scans from the Alzheimer's Disease Neuroimaging Initiative [ADNI], Baltimore Longitudinal Study of Aging [BLSA], and Biomarkers for Older Controls at Risk for Dementia [BIOCARD] data sets).

Conclusions and Relevance

This study characterized heterogeneity in LLD into 2 dimensions with distinct neuroanatomical, cognitive, clinical, and genetic profiles. This dimensional approach provides a potential mechanism for investigating the heterogeneity of LLD and the relevance of the latent dimensions to possible disease mechanisms, clinical outcomes, and responses to interventions.

Prediction of Lung Infection during Palliative Chemotherapy of Lung Cancer Based on Artificial Neural Network

Lung infection seriously affects the effect of chemotherapy in patients with lung cancer and increases pain. The study is aimed at establishing the prediction model of infection in patients with lung cancer during chemotherapy by an artificial neural network (ANN). Based on the data of historical cases in our hospital, the variables were screened, and the prediction model was established. A logistic regression (LR) model was used to screen the data. The indexes with statistical significance were selected, and the LR model and back propagation neural network model were established. A total of 80 cases of advanced lung cancer patients with palliative chemotherapy were predicted, and the prediction performance of different model was evaluated by the receiver operating characteristic curve (ROC). It was found that $\text{age}\geqq 60$ years, length of $\text{stay}\geqq 14$  d, surgery history, combined chemotherapy, myelosuppression, diabetes, and hormone application were risk factors of infection in lung cancer patients during chemotherapy. The area under the ROC curve of the LR model for prediction lung infection was $0.729\pm 0.084$ , which was less than that of the ANN model ( $0.897\pm 0.045$ ). The results concluded that the neural network model is better than the LR model in predicting lung infection of lung cancer patients during chemotherapy.

Dose-response effects of selective serotonin reuptake inhibitor monotherapy for the treatment of depression: systematic review of reviews and meta-narrative synthesis

Objective

To assess and clarify the relations between selective serotonin reuptake inhibitor (SSRI) dose efficacy, acceptability (early treatment discontinuation (dropouts)), and tolerability (reported adverse drug effects), and critically evaluate methods previously used to examine SSRI dose-response effects for the treatment of depression in adults.

Design

Systematic review of reviews and meta-narrative synthesis.

Data sources

Embase, Medline, PsycINFO, Scopus, and the Cochrane Collaboration library, from 1975 to December 2021. Reference lists of national depression treatment guidelines were systemically searched by hand.

Eligibility criteria for selecting studies

Reviews assessing SSRI monotherapy dose-response effects for the treatment of depression in adults (age ≥18 years) reporting efficacy, acceptability, or tolerability. Reviews meeting inclusion criteria had a high degree of heterogeneity, due to methodological diversity; therefore, a meta-narrative synthesis approach was applied. Standard daily doses were defined as 20 mg citalopram, fluoxetine, paroxetine; 50 mg sertraline; and 10 mg escitalopram. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, in line with Cochrane recommendations.

Results

The search identified 9138 records; 387 full text reports were assessed for eligibility, 42 of which matched the inclusion criteria. The majority, 83% (n=35), of reviews included data for studies with a duration of ≤12 weeks (ie, the acute phase of depression treatment). Of 39 reviews assessing efficacy, the majority (n=26) indicated that individual SSRIs and SSRI class demonstrated flat dose-response effects; standard doses were optimal for efficacy. Acceptability or tolerability were assessed in 28 reviews. Higher than standard daily doses were associated with higher dropout rates and a greater incidence of adverse drug effects (eg, nausea, sexual dysfunction, fatigue, anxiety). Despite a range of methods being reported, there was an overall consensus regarding SSRI dose related efficacy, dropouts, and adverse drug effects.

Conclusion

Standard daily doses of SSRIs for the treatment of depression in adults provide a favourable balance between efficacy, acceptability, and tolerability. Patients are encouraged to talk to their prescriber or community pharmacist if they experience adverse effects or have any concerns about their drug treatments.

Deficiency in the Essential Amino Acids l-Isoleucine, l-Leucine and l-Histidine and Clinical Measures as Predictors of Moderate Depression in Elderly Women: A Discriminant Analysis Study

Increases in depression are common in some elderly women. Elderly women often show moderate depressive symptoms, while others display minimal depressive symptoms. These discrepancies have produced contradictory and inconclusive outcomes, which have not been explained entirely by deficits in neurotransmitter precursors. Deficiency in some amino acids have been implicated in major depression, but its role in non-clinical elderly women is not well known. An analysis of essential amino acids, depression and the use of discriminant analysis can help to clarify the variation in depressive symptoms exhibited by some elderly women. The aim was to investigate the relationship of essential amino acids with affective, cognitive and comorbidity measures in elderly women without major depression nor severe mood disorders or psychosis, specifically thirty-six with moderate depressive symptoms and seventy-one with minimal depressive symptoms. The plasma concentrations of nineteen amino acids, Beck Depression Inventory (BDI) scores, Geriatric Depression Scale (GDS) scores, global cognitive scores and comorbidities were submitted to stepwise discriminant analysis to identify predictor variables. Seven predictors arose as important for belong to the group based on amino acid concentrations, with the moderate depressive symptoms group characterized by higher BDI, GDS and cognitive scores; fewer comorbidities; and lower levels of l-histidine, l-isoleucine and l-leucine. These findings suggest that elderly women classified as having moderate depressive symptoms displayed a deficiency in essential amino acids involved in metabolism, protein synthesis, inflammation and neurotransmission.

Characteristics of discharge prescriptions for patients with schizophrenia or major depressive disorder: Real-world evidence from the Effectiveness of Guidelines for Dissemination and Education (EGUIDE) psychiatric treatment project

BACKGROUND

Monopharmacy with antipsychotics and antidepressants is the first-line treatment for schizophrenia and major depressive disorder (MDD) in most clinical guidelines, while polypharmacy with psychotropic agents in the treatment of schizophrenia is common in clinical practice. There are no detailed data on the prescription patterns for inpatients with mental illness with reliable diagnoses made by treating psychiatrists.

METHODS

We gathered prescription data at discharge from 2177 patients with schizophrenia and 1238 patients with MDD from October 2016 to March 2018.

RESULTS

The patients with schizophrenia aged between 60 and 79 were prescribed lower doses of antipsychotics and hypnotics/anxiolytics than those aged between 40 and 59. There were significant differences between the prescription rate of antipsychotics in the patients with schizophrenia and that of antidepressants in the patients with MDD. The frequency of concomitant drugs such as anti-Parkinson drugs, anxiolytics/hypnotics and mood stabilizers in the subjects with schizophrenia prescribed antipsychotic polypharmacy was significantly higher than that with monotherapy. For the patients with schizophrenia, olanzapine, risperidone, aripiprazole, quetiapine, and blonanserin were the five most prescribed antipsychotics. For the patients with MDD, mirtazapine, duloxetine, escitalopram, trazodone and sertraline were the five most prescribed antidepressants.

CONCLUSIONS

Our results showed the use of high doses of antipsychotics, high percentages of antipsychotic polypharmacy and concurrent use of hypnotics/anxiolytics in patients with schizophrenia. Notably, these data were collected before intensive instruction regarding the guidelines; therefore, we need to assess the change in the prescription pattern post guideline instruction.

Differences in cause and 12-month follow-up outcome of parkinsonian symptoms in depressed older adults treated with antipsychotics: a case series

BACKGROUND

Parkinsonian symptoms are common adverse effects of antipsychotics. Older adults are particularly vulnerable to drug-induced parkinsonism. Nonetheless, parkinsonian symptoms in seniors treated with antipsychotics cannot be straightforwardly attributed to antipsychotic medication. A comprehensive diagnostic workup is necessary in many cases in order to shed light on the cause of such symptoms in this patient population.

CASE SERIES

Eight cases of hospitalized depressed older adults with parkinsonian symptoms, who were treated for at least one year with antipsychotics, are reported. Based on neurological consultation, structural brain imaging and Ioflupane (I-123) dopamine transporter (DAT) single photon emission computerized tomography (SPECT), Parkinson's disease was diagnosed in one case, idiopathic tremor in another, vascular parkinsonism in another one, while in another individual parkinsonian symptoms persisted at 12-month post-discharge follow-up even though his/her symptoms were classified as drug-induced on discharge. In four patients, parkinsonian symptoms were definitely drug-induced and no movement disturbances were reported at follow-up.

CONCLUSIONS

Differences in the cause and outcome of parkinsonian symptoms in seniors treated with antipsychotics merit systematic and in-depth study considering the therapeutic and prognostic implications of an accurate detection of the cause of such symptoms. Familiarizing clinical psychiatrists with these differences could pave the way towards approaching seniors with severe, atypical and/or persistent parkinsonian symptoms in a more individualized diagnostic and therapeutic manner, and towards more cautious prescribing of antipsychotics in this age group.

Recurrence of Mania or Depression Among Adult Bipolar Patients Who Continued Using Lithium: A Single-group Summary Meta-analysis of Randomized Trials

BACKGROUND

The exact recurrence rate of bipolar disorder in patients receiving lithium maintenance phase treatment and the modifiers associated with recurrence are still unknown.

METHODS

We searched Embase, PubMed, and CENTRAL from inception until April 28, 2020. Outcomes included recurrence rate of any mood episode, depressive episodes, and manic/hypomanic/mixed episodes; all-cause discontinuation rate; and discontinuation rate due to adverse events. A random-effects model, single-group summary meta-analysis was conducted. A meta-regression analysis to examine whether the modifiers (total number of patients, %female, mean age, duration of study, duration of preliminary phase, publication year, bipolar disorder type, mood status at recruitment, presence of a placebo arm, sponsorship, enrichment design, number of treatment arms, and risk of bias for blinding or randomization) were associated with the event rate of the outcomes was also performed.

RESULTS

We identified 21 randomized trials (n = 1,415; mean study duration, 78.40 ± 32.10 weeks; %female, 54.85%; mean age, 43.47 ± 4.88 years). The event rates (95% confidence interval [CI]) were as follows: recurrence of any mood episode, 39.8% (32.8%, 47.1%); depressive episodes, 25.6% (18.8%, 34.0%); manic/hypomanic/mixed episodes, 18.5% (13.7%, 24.7%); all-cause discontinuation rate, 67.0% (57.2%, 75.5%); and discontinuation rate due to adverse events, 8.7% (5.1%, 14.7%). After adjusting for multiple testing, our meta-regression analysis showed association only between the all-cause discontinuation rate and presence of a placebo arm.

CONCLUSIONS

The recurrence rate of depressive episodes seemed to be higher than the recurrence rate of manic/hypomanic/mixed episodes. The all-cause discontinuation rate was high. However, the studies included in our meta-analysis were of short duration.

Major Depressive Disorder in Older Patients as an Inflammatory Disorder: Implications for the Pharmacological Management of Geriatric Depression

Depression is a common and highly disabling condition in older adults. It is a heterogenous disorder and there is emerging evidence of a link between inflammation and depression in older patients, with a possible inflammatory subtype of depression. Persistent low-level inflammation, from several sources including psychological distress and chronic disease, can disrupt monoaminergic and glutaminergic systems to create dysfunctional brain networks. Despite the evidence for the role of inflammation in depression, there is insufficient evidence to recommend use of any putative anti-inflammatory agent in the treatment of depression in older adults at this stage. Further characterisation of markers of inflammation and stratification of participants with elevated rates of inflammatory markers in treatment trials is needed.

Comorbid Chronic Pain and Depression: Shared Risk Factors and Differential Antidepressant Effectiveness

The bidirectional relationship between depression and chronic pain is well-recognized, but their clinical management remains challenging. Here we characterize the shared risk factors and outcomes for their comorbidity in the Australian Genetics of Depression cohort study (N = 13,839). Participants completed online questionnaires about chronic pain, psychiatric symptoms, comorbidities, treatment response and general health. Logistic regression models were used to examine the relationship between chronic pain and clinical and demographic factors. Cumulative linked logistic regressions assessed the effect of chronic pain on treatment response for 10 different antidepressants. Chronic pain was associated with an increased risk of depression (OR = 1.86 [1.37-2.54]), recent suicide attempt (OR = 1.88 [1.14-3.09]), higher use of tobacco (OR = 1.05 [1.02-1.09]) and misuse of painkillers (e.g., opioids; OR = 1.31 [1.06-1.62]). Participants with comorbid chronic pain and depression reported fewer functional benefits from antidepressant use and lower benefits from sertraline (OR = 0.75 [0.68-0.83]), escitalopram (OR = 0.75 [0.67-0.85]) and venlafaxine (OR = 0.78 [0.68-0.88]) when compared to participants without chronic pain. Furthermore, participants taking sertraline (OR = 0.45 [0.30-0.67]), escitalopram (OR = 0.45 [0.27-0.74]) and citalopram (OR = 0.32 [0.15-0.67]) specifically for chronic pain (among other indications) reported lower benefits compared to other participants taking these same medications but not for chronic pain. These findings reveal novel insights into the complex relationship between chronic pain and depression. Treatment response analyses indicate differential effectiveness between particular antidepressants and poorer functional outcomes for these comorbid conditions. Further examination is warranted in targeted interventional clinical trials, which also include neuroimaging genetics and pharmacogenomics protocols. This work will advance the delineation of disease risk indicators and novel aetiological pathways for therapeutic intervention in comorbid pain and depression as well as other psychiatric comorbidities.

EEG as a Functional Marker of Nicotine Activity: Evidence From a Pilot Study of Adults With Late-Life Depression

Late-life depression (LLD) is a debilitating condition that is associated with poor response to antidepressant medications and deficits in cognitive performance. Nicotinic cholinergic stimulation has emerged as a potentially effective candidate to improve cognitive performance in patients with cognitive impairment. Previous studies of nicotinic stimulation in animal models and human populations with cognitive impairment led to examining potential cognitive and mood effects of nicotinic stimulation in older adults with LLD. We report results from a pilot study of transdermal nicotine in LLD testing whether nicotine treatment would enhance cognitive performance and mood. The study used electroencephalography (EEG) recordings as a tool to test for potential mechanisms underlying the effect of nicotine. Eight non-smoking participants with LLD completed EEG recordings at baseline and after 12 weeks of transdermal nicotine treatment (NCT02816138). Nicotine augmentation treatment was associated with improved performance on an auditory oddball task. Analysis of event-related oscillations showed that nicotine treatment was associated with reduced beta desynchronization at week 12 for both standard and target trials. The change in beta power on standard trials was also correlated with improvement in mood symptoms. This pilot study provides preliminary evidence for the impact of nicotine in modulating cortical activity and improving mood in depressed older adults and shows the utility of using EEG as a marker of functional engagement in nicotinic interventions in clinical geriatric patients.