Patients' and clinicians' perspectives on relevant treatment outcomes in depression: qualitative study

Evaluating the efficacy and mechanisms of a ketogenic diet as adjunctive treatment for people with treatment-resistant depression: A protocol for a randomised controlled trial

BACKGROUND

One-third of people with depression do not respond to antidepressants, and, after two adequate courses of antidepressants, are classified as having treatment-resistant depression (TRD). Some case reports suggest that ketogenic diets (KDs) may improve some mental illnesses, and preclinical data indicate that KDs can influence brain reward signalling, anhedonia, cortisol, and gut microbiome which are associated with depression. To date, no trials have examined the clinical effect of a KD on TRD.

METHODS

This is a proof-of-concept randomised controlled trial to investigate the efficacy of a six-week programme of weekly dietitian counselling plus provision of KD meals, compared with an intervention involving similar dietetic contact time and promoting a healthy diet with increased vegetable consumption and reduction in saturated fat, plus food vouchers to purchase healthier items. At 12 weeks we will assess whether participants have continued to follow the assigned diet. The primary outcome is the difference between groups in the change in Patient Health Questionnaire-9 (PHQ-9) score from baseline to 6 weeks. PHQ-9 will be measured at weeks 2, 4, 6 and 12. The secondary outcomes are the differences between groups in the change in remission of depression, change in anxiety score, functioning ability, quality of life, cognitive performance, reward sensitivity, and anhedonia from baseline to 6 and 12 weeks. We will also assess whether changes in reward sensitivity, anhedonia, cortisol awakening response and gut microbiome may explain any changes in depression severity.

DISCUSSION

This study will test whether a ketogenic diet is an effective intervention to reduce the severity of depression, anxiety and improve quality of life and functioning ability for people with treatment-resistant depression.

Primary outcome reporting in clinical trials for older adults with depression

BACKGROUND

Findings from randomised controlled trials (RCTs) are synthesised through meta-analyses, which inform evidence-based decision-making. When key details regarding trial outcomes are not fully reported, knowledge synthesis and uptake of findings into clinical practice are impeded.

AIMS

Our study assessed reporting of primary outcomes in RCTs for older adults with major depressive disorder (MDD).

METHOD

Trials published between 2011 and 2021, which assessed any intervention for adults aged ≥65 years with a MDD diagnosis, and that specified a single primary outcome were considered for inclusion in our study. Outcome reporting assessment was conducted independently and in duplicate with a 58-item checklist, used in developing the CONSORT-Outcomes statement, and information in each RCT was scored as 'fully reported', 'partially reported' or 'not reported', as applicable.

RESULTS

Thirty-one of 49 RCTs reported one primary outcome and were included in our study. Most trials (71%) did not fully report over half of the 58 checklist items. Items pertaining to outcome analyses and interpretation were fully reported by 65% or more of trials. Items reported less frequently included: outcome measurement instrument properties (varied from 3 to 30%) and justification of the criteria used to define clinically meaningful change (23%).

CONCLUSIONS

There is variability in how geriatric depression RCTs report primary outcomes, with omission of details regarding measurement, selection, justification and definition of clinically meaningful change. Outcome reporting deficiencies may hinder replicability and synthesis efforts that inform clinical guidelines and decision-making. The CONSORT-Outcomes guideline should be used when reporting geriatric depression RCTs.

Reflections on the group dynamic in a group cognitive behavioral therapy intervention for young adult women with moderate to severe dysmenorrhea: a qualitative analysis

A recent group cognitive behavioral therapy (gCBT) intervention for dysmenorrhea conducted by our team demonstrated feasibility, acceptability, and preliminary efficacy at reducing menstrual pain. This study aimed to use qualitative analyses to explore participants' reflections about the intervention's group dynamic. Participants included 20 young women ages 18-24 years with average menstrual pain of 8.0 (SD = 1.1) on a 0-10 (0 = none, 10 = worst pain possible) numeric rating scale. Semi-structured individual and group interviews were conducted after the intervention. Researchers then conducted deductive, iterative thematic analysis using a template analysis approach. Two themes were generated: benefit and logistics. The benefit theme included two sub-themes: (1) camaraderie (an emotional, psychological, or social connection between participants); and (2) sharing (information, advice, or experiences). The logistics theme highlighted how the structure of the group influenced the dynamic and was divided into two sub-themes according to the time frame being described: (1) reactions (participants' experiences with how the group dynamic was facilitated); and (2) future (how the group structure could be improved). Results of this study contribute to the growing body of literature related to gCBT for pain conditions. Future research is needed to optimize the group dynamic and evaluate its specific therapeutic role in the treatment.

A blended module (STAIRS) to promote functional and personal recovery in patients with a major depressive disorder in remission: study protocol of a concurrent mixed methods randomized controlled trial

BACKGROUND

Despite the availability of a wide variety of evidence-based treatments for major depressive disorder (MDD), many patients still experience impairments in their lives after remission. Programs are needed that effectively support patients in coping with these impairments. The program Storytelling and Training to Advance Individual Recovery Skills (STAIRS) was developed to address this need and combines the use of peer contact, expert-by-experience guidance, family support and professional blended care. The aim of the planned study is (1) to assess the efficacy of the STAIRS program in patients with remitted MDD, (2) to investigate patients' subjective experiences with STAIRS, and (3) to evaluate the program's cost-effectiveness.

METHODS

A concurrent mixed-methods randomized controlled trial design will be used. Patients aged between 18 and 65 years with remitted MDD (N = 140) will be randomized to either a group receiving care as usual (CAU) + the STAIRS-program or a control group receiving CAU + some basic psychoeducation. Quantitative efficacy data on functional and personal recovery and associated aspects will be collected using self-report questionnaires at the start of the intervention, immediately following the intervention, and at the six-month follow-up. Insights into patients' experiences on perceived effects and the way in which different program elements contribute to this effect, as well as the usability and acceptability of the program, will be gained by conducting qualitative interviews with patients from the experimental group, who are selected using maximum variation sampling. Finally, data on healthcare resource use, productivity loss and quality of life will be collected and analysed to assess the cost-effectiveness and cost-utility of the STAIRS-program.

DISCUSSION

Well-designed recovery-oriented programs for patients suffering from MDD are scarce. If efficacy and cost-effectiveness are demonstrated with this study and patients experience the STAIRS program as usable and acceptable, this program can be a valuable addition to CAU. The qualitative interviews may give insights into what works for whom, which can be used to promote implementation.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov on 1 July 2021, registration number NCT05440812.

Nonresponder does not mean not better: Improvement in nonsymptom domains in complex depressed patients who are not symptomatic responders to intensive treatment

In treatment studies of depression, response is typically defined as a 50% or greater reduction in symptom severity. However, multiple surveys of depressed patients have found that patients prioritize improved functioning and quality of life objectives over symptom improvement as the most important goal of treatment. The goal of the present study is to widen the lens of assessing outcome by examining response in nonsymptom domains in patients who are, by convention, considered nonresponders to treatment. Eight hundred and forty-four patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. At discharge, the patients made a global rating of the effectiveness of treatment. The 517 patients who were nonresponders on the depression symptom subscale of the RDQ are the focus of this report. The patients showed significant levels of improvement from admission to discharge in all nonsymptom domains, with medium to large effect sizes. Approximately one-third of the patients were responders on at least 1 of the nonsymptom domains. The failure to meet the conventional definition of treatment response based on symptom severity does not preclude significant improvement in nonsymptom domains.

Single-dose psilocybin for a treatment-resistant episode of major depression: Impact on patient-reported depression severity, anxiety, function, and quality of life

BACKGROUND

COMP360 is a proprietary, synthetic formulation of psilocybin being developed for treatment-resistant depression (TRD), a burdensome, life-threatening illness with high global impact. Here, we expand upon the previous report of primary outcomes from a phase 2 study of COMP360 in individuals with TRD-the largest randomised controlled clinical trial of psilocybin-to discuss findings of the exploratory efficacy endpoints.

METHODS

In this phase 2, double-blind trial, 233 participants with TRD were randomised to receive a single dose of psilocybin 25 mg, 10 mg, or 1 mg (control), administered alongside psychological support from trained therapists. Efficacy measures assessed patient-reported depression severity, anxiety, positive and negative affect, functioning and associated disability, quality of life, and cognitive function.

RESULTS

At Week 3, psilocybin 25 mg, compared with 1 mg, was associated with greater improvements from Baseline total scores in all measures. The 10 mg dose produced smaller effects across these measures.

LIMITATIONS

Interpretation of this trial is limited by the absence of an active comparator and the possibility of functional unblinding in participants who received a low dose of psilocybin.

CONCLUSIONS

Three weeks after dosing, psilocybin 25 mg and, to a lesser degree, 10 mg improved measures of patient-reported depression severity, anxiety, affect, and functioning. These results extend the primary findings from the largest randomised clinical trial of psilocybin for TRD to examine other outcomes that are of importance to patients.

The Case for the Patient-Centric Development of Novel Digital Sleep Assessment Tools in Major Depressive Disorder

Background

Depression imposes a major burden on public health as the leading cause of disability worldwide. Sleep disturbance is a core symptom of depression that affects the vast majority of patients. Nonetheless, it is frequently not resolved by depression treatment and may even be worsened through some pharmaceutical interventions. Disturbed sleep negatively impact patients' quality of life, and persistent sleep disturbance increases the risk of recurrence, relapse, and even suicide. However, the development of novel treatments that might improve sleep problems is hindered by the lack of reliable low-burden objective measures that can adequately assess disturbed sleep in this population.

Summary

Developing improved digital measurement tools that are fit for use in clinical trials for major depressive disorder could promote the inclusion of sleep as a focus for treatment, clinical drug development, and research. This perspective piece explores the path toward the development of novel digital measures, reviews the existing evidence on the meaningfulness of sleep in depression, and summarizes existing methods of sleep assessments, including the use of digital health technologies.

Key Messages

Our objective was to make a clear call to action and path forward for the qualification of new digital outcome measures which would enable assessment of sleep disturbance as an aspect of health that truly matters to patients, promoting sleep as an important outcome for clinical development, and ultimately ensure that disturbed sleep will not remain the forgotten symptom of depression.

In pursuit of full recovery in major depressive disorder

Many individuals with major depression disorder (MDD) who achieve remission of depressive symptoms, do not perceive themselves as fully recovered. This study explores whether clinical remission is related to functional remission and to patient's perception of recovery, as well as, which factors are associated with their functional and subjective remission. 148 patients with MDD in partial clinical remission were included. Demographics and clinical variables were collected through semi-structured interviews. Objective cognition was evaluated through a neuropsychological battery and subjective cognition through a specific questionnaire. The patient's psychosocial functioning and the perception of their remission were also assessed. Apart from descriptive analysis, Pearson correlations and backward stepwise regression models explored the relationship between demographic, clinical, and cognitive factors with patients' functional and self-perceived remission. From the whole sample, 57 patients (38.5%) were considered to achieve full clinical remission, 38 patients (25.7%) showed functional remission, and 55 patients (37.2%) perceived themselves as remitted. Depressive symptoms and objective and subjective executive function were the factors associated with psychosocial functioning. Besides, depressive symptoms, objective and subjective attention, and subjective executive function were the significant explanatory variables for self-perception of remission. The concept of full recovery from an episode of MDD should not only include the clinician's perspective but also the patient's psychosocial functioning along with their self-perceived remission. As residual depressive symptoms and cognition (objective and subjective) are factors with great contribution to a full recovery, clinicians should specifically address them when choosing therapeutic strategies.

Randomized clinical trial of integral cognitive remediation program for major depression (INCREM)

BACKGROUND

Despite achieving clinical remission, patients with depression encounter difficulties to return to their premorbid psychosocial functioning. Cognitive dysfunction has been proposed to be a primary mediator of functional impairment. Therefore, the new non-pharmacological procognitive strategy INtegral Cognitive REMediation for Depression (INCREM) has been developed with the aim of targeting cognitive and psychosocial functioning.

METHODS

This is a single-blind randomized controlled clinical trial with three treatment arms. Fifty-two depressed patients in clinical remission, with psychosocial difficulties and cognitive impairment, were randomly assigned to receive INCREM intervention, Psychoeducation programme, or treatment as usual. Patients were assessed before and after the study period, and six months after. The primary outcome was the change from baseline of patients' psychosocial functioning. Changes in cognitive functioning and other variables were considered secondary outcomes.

RESULTS

The analysis showed a significant improvement in psychosocial functioning in the INCREM group, especially six months after the intervention, compared to patients who received the psychoeducation programme. An improvement in cognitive performance was also observed in the INCREM group.

LIMITATIONS

This study includes a small sample size due to the anticipated end of the clinical trial because of the COVID-19 pandemic.

DISCUSSION

These results provide preliminary evidence on the feasibility and potential efficacy of the INCREM program to improve not only cognitive performance but also psychosocial functioning in clinically remitted depressed patients, and such improvement is maintained six months after. It can be speculated that the maintenance is mediated by the cognitive enhancement achieved with INCREM.

Emotional blunting in patients with depression. Part IV: differences between patient and physician perceptions

BACKGROUND

Emotional blunting is common in patients with depression. An online survey was undertaken to assess the experience of emotional blunting, and its impact on functioning and quality of life, in the acute and remission phases of depression from the perspective of patients and healthcare providers (HCPs). This paper presents data on the level of concordance between patient and HCP perspectives.

METHODS

This was a cross-sectional, observational study. Patient respondents were adults with a diagnosis of depression, who were currently using a prescribed antidepressant, and who reported emotional blunting during the past 6 weeks. HCPs completed the survey for the last two eligible patients they had seen, one in each phase of depression. Assessments included the Oxford Depression Questionnaire (ODQ) 'antidepressant as cause' domain and the Functioning Assessment Short Test (FAST).

RESULTS

Mean ODQ 'antidepressant as cause' domain scores were significantly higher in the patient-reported cohort (n = 752) than in the HCP-assessed cohort (n = 766) in both the acute (18.0 vs 12.5, respectively; p < 0.01) and remission phases (17.6 vs 12.6; p < 0.01). Overall, 45% of patients believed that their antidepressant medication was negatively affecting their emotions and 39% were considering stopping or had stopped their antidepressant because of perceived emotion-related side effects. In the HCP-assessed cohort, the antidepressant was considered responsible for emotional blunting in 30% of patients and only 18% of patients were believed to be considering stopping their medication due to emotional blunting. Patients reported a greater impact of emotional blunting on activities of daily living than HCPs. Mean FAST score was significantly higher in each phase of depression in the patient-reported cohort than in the HCP-assessed cohort (acute phase, 47.0 vs 39.1; remission phase, 33.5 vs 19.4; both p < 0.01).

CONCLUSIONS

Compared with previous studies, our results suggest that HCPs may underestimate the prevalence of emotional blunting in patients with depression. HCPs also appear to underestimate the severity and impact of emotional blunting on patient functioning and treatment adherence compared with patients' own perspectives. Differences between patient and HCP perspectives were most pronounced during the acute phase of the disease.

Emotional blunting in patients with depression. Part III: relationship with psychological trauma

BACKGROUND

This international online survey investigated the experience and impact of emotional blunting in the acute and remission phases of depression from the perspective of patients and healthcare providers (HCPs). This paper presents data on the history and severity of psychological trauma and its potential impact on emotional blunting in major depressive disorder (MDD); differences between patient and HCP perceptions are explored.

METHODS

Patient respondents (n = 752) were adults with a diagnosis of depression who were currently taking antidepressant therapy and reported emotional blunting during the past 6 weeks. HCPs provided details on two eligible patients: one in the acute phase of depression and one in remission from depression (n = 766). Trauma was assessed using questions based on the Childhood Trauma Questionnaire; emotional blunting was assessed using the Oxford Depression Questionnaire (ODQ). Multivariate regression analyses were applied to examine the relationship between trauma and ODQ score.

RESULTS

A history of any childhood or recent traumatic event was reported by 97% of patients in the self-assessed cohort and for 83% of those in the HCP-assessed cohort (difference, p < 0.01). Patients were more likely than HCPs to feel that this trauma had contributed to their/the patient's depression (58% vs 43%, respectively; p < 0.01) and that the depression was more severe because of trauma (70% vs 61%, respectively; p < 0.01). Emotional blunting was significantly worse in patients who reported severe trauma than in those who had not experienced severe trauma (mean total ODQ score, 90.1 vs 83.9, respectively; p < 0.01). In multivariate regression analyses, experiencing both severe childhood and recent trauma had a statistically significant impact on ODQ total score (p = 0.001).

CONCLUSIONS

A high proportion of patients with depression and emotional blunting self-reported exposure to childhood and/or recent traumatic events, and emotional blunting was more severe in patients who reported having experienced severe trauma. However, history of psychological trauma in patients with MDD appeared to be under-recognized by HCPs. Improved recognition of patients who have experienced psychological trauma and are experiencing emotional blunting may permit more targeted therapeutic interventions, potentially resulting in improved treatment outcomes.

Individual treatment goals and factors influencing goal attainment in patients with somatic symptom disorder from the perspective of clinicians: A concept mapping study

OBJECTIVE

Overviews of treatment goals and influencing factors may support shared decision making and optimize customized treatment to the patient with somatic symptom disorder (SSD). The aim of this study was to identify and structure comprehensive sets of treatment goals and factors influencing goal attainment in patients with SSD from the perspective of clinicians.

METHODS

Using a concept mapping procedure, clinicians participated in interviews (N = 17) and card sorting tasks comprising 55 treatment goals and 55 factors influencing goal attainment (N = 38).

RESULTS

We identified four overarching categories (A to D) of nine clusters (1 to 9) of treatment goals: A. empowerment (A1. personal values, A2. committed action, A3. self-esteem), B. skill improvement (B4. interpersonal skills, B5. emotion and stress regulation), C. symptom reduction (C6. dysfunctional beliefs, C7. somatic symptoms, C8. psychological symptoms), and D9. active and structured lifestyle. Also, we identified four overarching categories (A to D) of nine clusters (1 to 9) of factors influencing goal attainment: A1. therapeutic alliance, B. social and everyday context (B2. [family] system, B3. meaningful daily schedule, B4. social and economic circumstances), C. ability to change (C5. externalizing tendency, C6. reflective and psychological skills, C7. perspective and motivation), and D. psychological vulnerability (D8. vulnerable personality, D9. [psychiatric] comorbidity).

CONCLUSION

The overviews of treatment goals and factors influencing goal attainment reflect different paradigmatic backgrounds of clinicians. The results can be used, in combination with the perspective of the patient, to define treatment goals, and to monitor and evaluate change in outcomes.

Effectiveness of Vortioxetine in Patients With Major Depressive Disorder in Real-World Clinical Practice: Results of the RELIEVE Study

BACKGROUND

Randomized controlled clinical trials have shown vortioxetine to be efficacious and well tolerated for the treatment of major depressive disorder (MDD). The Real-Life Effectiveness of Vortioxetine in Depression (RELIEVE) study was undertaken to demonstrate the effectiveness and safety of vortioxetine for the treatment of MDD in routine clinical practice.

METHODS

RELIEVE was a 24-week, observational, prospective cohort study in outpatients with MDD initiating treatment with vortioxetine at their physician's discretion in routine care settings in Canada, France, Italy, and the USA (NCT03555136). The primary study outcome was patient functioning assessed by the Sheehan Disability Scale (SDS). Secondary outcomes included depression severity [9-item Patient Health Questionnaire (PHQ-9)], cognitive symptoms [5-item Perceived Deficits Questionnaire-Depression (PDQ-D-5)], and cognitive performance [Digit Symbol Substitution Test (DSST)]. Mixed models of repeated measures were used to assess change from baseline at week 24, adjusted for relevant confounders.

RESULTS

A total of 737 patients were eligible for inclusion in the full analysis set. Most patients (73.7%) reported at least one comorbid medical condition, 56.0% had comorbid anxiety and 24.4% had comorbid generalized anxiety disorder. Improvement in least-squares (LS) mean SDS score from baseline to week 24 was 8.7 points. LS mean PHQ-9, PDQ-D-5 and DSST scores improved by 7.4, 4.6, and 6.2 points, respectively. Adverse events were observed in 21.2% of patients [most commonly, nausea (8.2% of patients)].

CONCLUSIONS

These results demonstrate the effectiveness and tolerability of vortioxetine for the treatment of MDD in a large and heterogeneous patient population representative of that encountered in routine clinical practice.

Patient Expectations and Experiences of Antidepressant Therapy for Major Depressive Disorder: A Qualitative Study

PURPOSE

This qualitative study explored patient perceptions of the most burdensome symptoms of major depressive disorder (MDD), the impact of symptoms on patients' daily lives, and patient expectations and experiences regarding the timing of onset of antidepressant pharmacotherapy.

PATIENTS AND METHODS

Data were collected through facilitated, patient focus-group sessions in the USA between May and June 2019. Participants were adults with confirmed MDD who reported a major depressive episode within the past 2 years, for which they had received pharmacologic treatment for ≥6 weeks. The semi-structured discussion focused on the key topics of bothersome symptoms of MDD, the impact of symptoms on quality of life, and the effects of antidepressant treatment. Interviews were audio-recorded; findings were summarized using a content-analysis approach.

RESULTS

Five focus-group sessions were undertaken, involving a total of 29 patients (each attended one session; mean age, 43.4 years; 72.4% female). Mean time since confirmed diagnosis of MDD was 13.1 years. The most commonly prescribed antidepressants received were bupropion (41.4% of participants), escitalopram (34.5%), and sertraline (34.5%). The most frequently reported bothersome MDD symptoms were fatigue (mentioned by 58.6% of participants), lack of motivation/loss of interest (51.7%), anxiety/panic (44.8%), sadness (41.4%), and lack of concentration/brain fog (41.4%). Socialization, family life, and work were the areas in which quality of life was most impacted. Participants expressed dissatisfaction with their antidepressant treatment. Fast symptom resolution was mentioned as a priority (defined as <1 week by 38.5% of participants and ≤1 month by 65.4%). Most participants had not experienced fast relief from their symptoms with current or previous antidepressant medications.

CONCLUSION

Results of this qualitative study suggest that fatigue, anhedonia, cognitive symptoms, and anxiety are some of the most bothersome symptoms for patients with MDD and highlight the importance of obtaining rapid relief from these symptoms in order to improve outcomes and patient satisfaction with antidepressant medication.