Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy

The burden of major depressive disorder in the Middle East and North Africa region, 1990-2019

BACKGROUND

Major depressive disorder (MDD) is one of the leading causes of disability. We aimed to report the MDD-attributable prevalence, incidence and years lived with disability (YLDs) in the Middle East and North Africa (MENA) region from 1990 to 2019 by age, sex and socio-demographic index (SDI).

METHODS

Publicly available data on the burden of MDD were retrieved from the Global Burden of Disease (GBD) study 2019 for the 21 countries in MENA. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals.

RESULTS

In 2019, MDD had an age-standardised point prevalence of 3322.1 and an incidence rate of 4921.7 per 100,000 population in MENA. Furthermore, there were 4.1 million YLDs in 2019. However, there were no substantial changes in the MDD burden over the period 1990-2019. In 2019, Palestine had the highest burden of MDD. The highest prevalence, incidence and YLDs attributable to MDD were found in the 35-39 age group. In 2019, the YLD rate in MENA was higher than the global rate for almost all age groups. Furthermore, there was a broadly negative association between the YLD rate and SDI.

CONCLUSION

The study highlights the need to prevent the disorder using a multidisciplinary approach and for the provision of cost-effective treatments for those affected, in order to increase their quality of life.

Efficacy and Safety of Antidepressants in Patients With Comorbid Depression and Medical Diseases: An Umbrella Systematic Review and Meta-Analysis

Importance

Every third to sixth patient with medical diseases receives antidepressants, but regulatory trials typically exclude comorbid medical diseases. Meta-analyses of antidepressants have shown small to medium effect sizes, but generalizability to clinical settings is unclear, where medical comorbidity is highly prevalent.

Objective

To perform an umbrella systematic review of the meta-analytic evidence and meta-analysis of the efficacy and safety of antidepressant use in populations with medical diseases and comorbid depression.

Data Sources

PubMed and EMBASE were searched from inception until March 31, 2023, for systematic reviews with or without meta-analyses of randomized clinical trials (RCTs) examining the efficacy and safety of antidepressants for treatment or prevention of comorbid depression in any medical disease.

Study Selection

Meta-analyses of placebo- or active-controlled RCTs studying antidepressants for depression in individuals with medical diseases.

Data Extraction and Synthesis

Data extraction and quality assessment using A Measurement Tool for the Assessment of Multiple Systematic Reviews (AMSTAR-2 and AMSTAR-Content) were performed by pairs of independent reviewers following PRISMA guidelines. When several meta-analyses studied the same medical disease, the largest meta-analysis was included. Random-effects meta-analyses pooled data on the primary outcome (efficacy), key secondary outcomes (acceptability and tolerability), and additional secondary outcomes (response and remission).

Main Outcomes and Measures

Antidepressant efficacy presented as standardized mean differences (SMDs) and tolerability (discontinuation for adverse effects) and acceptability (all-cause discontinuation) presented as risk ratios (RRs).

Results

Of 6587 references, 176 systematic reviews were identified in 43 medical diseases. Altogether, 52 meta-analyses in 27 medical diseases were included in the evidence synthesis (mean [SD] AMSTAR-2 quality score, 9.3 [3.1], with a maximum possible of 16; mean [SD] AMSTAR-Content score, 2.4 [1.9], with a maximum possible of 9). Across medical diseases (23 meta-analyses), antidepressants improved depression vs placebo (SMD, 0.42 [95% CI, 0.30-0.54]; I2 = 76.5%), with the largest SMDs for myocardial infarction (SMD, 1.38 [95% CI, 0.82-1.93]), functional chest pain (SMD, 0.87 [95% CI, 0.08-1.67]), and coronary artery disease (SMD, 0.83 [95% CI, 0.32-1.33]) and the smallest for low back pain (SMD, 0.06 [95% CI, 0.17-0.39]) and traumatic brain injury (SMD, 0.08 [95% CI, -0.28 to 0.45]). Antidepressants showed worse acceptability (24 meta-analyses; RR, 1.17 [95% CI, 1.02-1.32]) and tolerability (18 meta-analyses; RR, 1.39 [95% CI, 1.13-1.64]) compared with placebo. Antidepressants led to higher rates of response (8 meta-analyses; RR, 1.54 [95% CI, 1.14-1.94]) and remission (6 meta-analyses; RR, 1.43 [95% CI, 1.25-1.61]) than placebo. Antidepressants more likely prevented depression than placebo (7 meta-analyses; RR, 0.43 [95% CI, 0.33-0.53]).

Conclusions and Relevance

The results of this umbrella systematic review of meta-analyses found that antidepressants are effective and safe in treating and preventing depression in patients with comorbid medical disease. However, few large, high-quality RCTs exist in most medical diseases.

Cognitive behavioral therapies for depression and anxiety in people with chronic disease: A systematic review and meta-analysis

OBJECTIVE

Anxiety and depression in chronic disease are common and burdensome co-morbidities. There has been growing interest in cognitive and behavioral therapies (CBTs) for anxiety and depression in chronic disease, however their efficacy has not been well-established. This study examined the efficacy of CBTs for depression and/or anxiety symptoms within chronic disease and explored the moderating role of clinical and methodological characteristics.

METHODS

Following prospective registration, electronic databases were searched up to 2023 for randomized controlled trials (RCTs) examining CBTs for depression and/or anxiety in any adult chronic disease population.

RESULTS

We included 56 RCTs. The overall effect of CBTs was g = 0.61 (95% CI, 0.49, 0.72) for depression and g = 0.56 (95% CI, 0.42, 0.70) for anxiety. A range of methodological features significantly moderated the effect sizes obtained, including type of control group and the outcome measure used. Risk of Bias ratings indicated some concerns regarding RCT conduct and reporting.

CONCLUSIONS

CBTs lead to moderate improvements in both depression and anxiety symptoms among people with chronic disease. However, the efficacy of CBT should be interpreted considering certain study and sample characteristics. It is recommended that future studies make improvements to study methodology and reporting.

Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.

Comorbidity between major depressive disorder and physical diseases: a comprehensive review of epidemiology, mechanisms and management

Populations with common physical diseases - such as cardiovascular diseases, cancer and neurodegenerative disorders - experience substantially higher rates of major depressive disorder (MDD) than the general population. On the other hand, people living with MDD have a greater risk for many physical diseases. This high level of comorbidity is associated with worse outcomes, reduced adherence to treatment, increased mortality, and greater health care utilization and costs. Comorbidity can also result in a range of clinical challenges, such as a more complicated therapeutic alliance, issues pertaining to adaptive health behaviors, drug-drug interactions and adverse events induced by medications used for physical and mental disorders. Potential explanations for the high prevalence of the above comorbidity involve shared genetic and biological pathways. These latter include inflammation, the gut microbiome, mitochondrial function and energy metabolism, hypothalamic-pituitary-adrenal axis dysregulation, and brain structure and function. Furthermore, MDD and physical diseases have in common several antecedents related to social factors (e.g., socioeconomic status), lifestyle variables (e.g., physical activity, diet, sleep), and stressful live events (e.g., childhood trauma). Pharmacotherapies and psychotherapies are effective treatments for comorbid MDD, and the introduction of lifestyle interventions as well as collaborative care models and digital technologies provide promising strategies for improving management. This paper aims to provide a detailed overview of the epidemiology of the comorbidity of MDD and specific physical diseases, including prevalence and bidirectional risk; of shared biological pathways potentially implicated in the pathogenesis of MDD and common physical diseases; of socio-environmental factors that serve as both shared risk and protective factors; and of management of MDD and physical diseases, including prevention and treatment. We conclude with future directions and emerging research related to optimal care of people with comorbid MDD and physical diseases.

Antidepressant treatment in patients following acute coronary syndromes: a systematic review and Bayesian meta-analysis

AIMS

The aim of this study is to investigate the effect of antidepressant therapy on mortality and cardiovascular outcomes in patients with acute coronary syndrome (ACS).

METHODS AND RESULTS

We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and performed a Bayesian random-effects meta-analysis of randomized controlled trials that investigated antidepressant pharmacotherapy in patients following ACS. The primary outcome was all-cause mortality. Secondary outcomes were repeat hospitalizations and recurrent myocardial infarctions (MIs). Ten randomized controlled trials with a total of 1935 patients qualified for inclusion. Selective serotonin reuptake inhibitors were investigated in six, bupropion in three, and mirtazapine in one trial. Placebo was used as control in eight trials. There was no difference in all-cause mortality [odds ratio (OR) 0.97, 95% credible interval (CrI) 0.66-1.42] and recurrent MI (OR 0.64, 95% CrI 0.40-1.02) between patients receiving antidepressants compared with controls, whereas antidepressant therapy was associated with less repeat hospitalizations (OR 0.62, 95% CrI 0.40-0.94). In patients with ACS and concomitant depression, antidepressants reduced the odds of recurrent MI compared with usual care/placebo (OR 0.45, 95% CrI 0.25-0.81). Extended funnel plots suggest robustness of the observations.

CONCLUSIONS

Antidepressants in patients following ACS have no effect on mortality but reduce repeat hospitalizations; in patients with depression, there is a reduced risk of recurrent MI with antidepressant therapy.

Relaxation techniques for depressive disorders in adults: a systematic review and meta-analysis of randomised controlled trials

Objectives: The aim of this study was to identify, evaluate, and synthesise existing randomised controlled trials (RCTs) that examined the effect of relaxation techniques in the treatment of patients with depressive disorders.Methods: A systematic review of the literature was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.Results: Nine studies were finally included in this meta-analysis. It was found that relaxation techniques might effectively reduce depressive symptoms among adults with depression (standardised mean difference (SMD) -0.42, 95% CI -0.72 to -0.11, p  =  0.008).Conclusions: Relaxation techniques are cost-effective, safe, and low-risk techniques that can be easily taught and used. Consequently, they have several benefits if practised regularly daily for more than an 8-week period.KEY POINTS/HIGHLIGHTSThe implication of this study for practice is that these relaxation techniques, cost-effective, safe, and low-risk techniques that can be easily taught and used.Consequently, practitioners will access benefits if practised regularly daily for more than an 8-week period.The relaxation technique is not complex, does not need any special device or place, does not need any change in lifestyle and is easily learned.

Pharmacological interventions for the treatment of psychological distress in patients with asthma: a systematic review and meta-analysis

Objective: To evaluate the effectiveness and safety of pharmacological interventions for the treatment of psychological distress in people with asthma.Data sources: Electronic searches were performed in Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed/Medline, Embase, PsycInfo, Health Technology Assessment Database and Web of Science (inception to April 2019).Study selections: Included studies were randomized controlled trials (RCT) or controlled clinical trials investigating the effect of pharmacological interventions for psychological distress in people with asthma. Records were screened and data extracted by two independent authors into standardized pilot-tested extraction templates. Data was analyzed according to standard Cochrane methodology and entered into Review Manager Software version 5.3.Results: From 5,689 studies, six RCTs (n = 215) met inclusion criteria and were included in the systematic review, of which four studies were included in the meta-analysis. A meta-analysis of four studies (n = 158) indicated no evidence of an effect for selective serotonin reuptake inhibitors (Citalopram or Escitalopram) on reduction of psychological distress in adult patients with asthma. Similarly, antiepileptic medication (Levetiracetam) was no better than placebo in the treatment of psychological distress in people with asthma. Adverse events were poorly reported across all studies but were slightly increased among intervention participants compared to control participants.Conclusions: There was great heterogeneity between studies and overall poor methodological quality providing insufficient evidence to make recommendations for or against the use of pharmacotherapy in asthma patients with psychological distress. Further confirmatory trials are warranted to make recommendations for clinical practice.

Hypothesis: neural mechanism of psychotherapy for the treatment of Parkinson's disease: cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and Morita therapy?

Cognitive behavioral therapy (CBT) for depression and anxiety, established since the 1960s in the USA, and now in Europe, and all over the world has been found to be effective for treating depression in Parkinson's disease (PD). CBT is further developed to acceptance and commitment therapy (ACT) in Europe and the USA. The neural mechanism of CBT or ACT is still under investigation. In Japan, Morita therapy, a psychotherapy founded in 1919 by Masatake (Shoma) Morita, has been used for common mental problems such as anxiety and depression, but rarely for the psychological symptoms in PD. Morita Therapy is in sharp contrast to western CBT in teaching that undesired mental symptoms such as anxiety and depression are natural features of human emotion in health and disease rather than something to control or eliminate, but it is speculated to be similar to ACT in the approach to acceptance but not elimination of mental symptoms. I speculate that the neural basis might be similar in CBT, ACT, and Morita Therapy. In this commentary, a hypothesis is proposed that CBT, ACT, as well as Morita Therapy might be effective for the treatment of the psychological symptoms such as anxiety and depression in PD and in other mental and physical diseases, probably by similar neural mechanisms in the brain.

Guidelines for the diagnosis and treatment of depressive disorders in China: The second edition

BACKGROUND

The recent guidelines for depressive disorders in China are based on both the first edition published in 2003, and new scientific evidence reviewed until the end of 2014. The purpose of the guidelines is to provide a comprehensive overview of the scientific evidence for the diagnosis and treatment of depressive disorders for Chinese patients.

METHODS

The data used in the guidelines were extracted from the recent literature, and various international treatment guidelines.

RESULTS

The current (second) guidelines are based on both evidence-based and measurement-based approaches. Comprehensive and regular assessments with standard instruments are recommended in the acute, continuation, and maintenance treatment phases, and the stage prior to the termination of treatment. In order to reduce the risk of relapse, the new guidelines are extended to the entire course of treatment. Recommendations for pharmacotherapeutic and other treatment modalities are described in detail.

CONCLUSIONS

Although major advances have been made compared to the 2003 edition of the guidelines, more intensive research is needed to optimize diagnosis and treatment of depressive disorders in China. The new guidelines provide only recommendations for diagnosis and treatment, therefore clinicians should develop individualized treatment plans along the lines of the comprehensive information obtained from patients and their families.

Effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases: a protocol for a systematic review and meta-analysis

INTRODUCTION

Depression is a global-scale public health problem, and a significant association has been established between depression and chronic physical diseases. This growing comorbidity poses a challenge to healthcare systems. We aim to assess the effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis of randomised clinical trials. Two databases MEDLINE and Cochrane Library (Cochrane Database for Systematic Reviews and CENTRAL), as well as the reference lists of the included articles, will be searched for studies either in English or Spanish with published results within the 2005-2015 period. Studies must fulfil the following conditions: (1) participants aged 18 years or older, diagnosed as having a major depressive episodes/disorder according to standardised criteria and chronic physical diseases; (2)interventions (be it pharmacological, psychological, psychosocial or a combination) must be compared with control conditions (other 'active' intervention, treatment as usual, waiting list or placebo); (3)and must report reduction in depressive symptoms after treatment, response to treatment, remission of major depressive episodes/disorder and significant improvement in quality of life. Data extraction, risk of bias evaluation, results summarisation and quality of the evidence (GRADE) will be performed as recommended by the Cochrane Collaboration. A qualitative synthesis and a random effects meta-analysis will be carried out. Effect sizes will be calculated (relative risk and Cohen's d), I² and Q statistics will be employed to study heterogeneity and publication bias analysis will be performed. Subgroup analyses and meta-regression will be carried out.

ETHICS AND DISSEMINATION

Results are expected to be published in specialised peer-reviewed journals (preferred topics: Mental Health, Psychology, Psychiatry and/or Systematic Reviews) and dissemination activities will be targeted to all the healthcare providers.

TRIAL REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (CRD42016029166) submitted on 11 January 2016.

Current Psychosomatic Practice

Psychosomatic research has advanced over the past decades in dealing with complex biopsychosocial phenomena and may provide new effective modalities of patient care. Among psychosocial variables affecting individual vulnerability, course, and outcome of any medical disease, the role of chronic stress (allostatic load/overload) has emerged as a crucial factor. Assessment strategies include the Diagnostic Criteria for Psychosomatic Research. They are presented here in an updated version based on insights derived from studies carried out so far and encompass allostatic overload, type A behavior, alexithymia, the spectrum of maladaptive illness behavior, demoralization, irritable mood, and somatic symptoms secondary to a psychiatric disorder. Macroanalysis is a helpful tool for identifying the relationships between biological and psychosocial variables and the individual targets for medical intervention. The personalized and holistic approach to the patient includes integration of medical and psychological therapies in all phases of illness. In this respect, the development of a new psychotherapeutic modality, Well-Being Therapy, seems to be promising. The growth of subspecialties, such as psychooncology and psychodermatology, drives towards the multidisciplinary organization of health care to overcome artificial boundaries. There have been major transformations in health care needs in the past decades. From psychosomatic medicine, a land of innovative hypotheses and trends, many indications for changes in the current practice of medicine are now at hand. The aim of this critical review is to outline current and potential clinical applications of psychosomatic methods.

Effect of chronic somatic diseases on the course of late-life depression

OBJECTIVE

To examine the influence of specific chronic somatic diseases and overall somatic diseases burden on the course of depression in older persons.

METHODS

This was a prospective cohort study with a 2-year follow-up. Participants were depressed persons (n = 285) from the Netherlands Study of Depression in Older Persons. The presence of chronic somatic diseases was based on self-report. Diagnosis of depression was assessed with the Composite International Diagnostic Interview, and severity of depression was measured with the Inventory of Depressive Symptomatology Self-report.

RESULTS

Cardiovascular diseases (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.02-2.72, p = 0.041), musculoskeletal diseases (OR = 1.71, 95% CI = 1.04-2.80, p = 0.034), and the number of chronic somatic diseases (OR = 1.37, 95% CI = 1.16-1.63, p < 0.001) were associated with having a depressive disorder at 2-year follow-up. Furthermore, chronic non-specific lung diseases, cardiovascular diseases, musculoskeletal diseases, cancer, or cumulative somatic disease burden were associated with a chronic course of depression.

CONCLUSIONS

Somatic disease burden is associated with a poor course of late-life depression. The course of late-life depression is particularly unfavorable in the presence of chronic non-specific lung diseases, cardiovascular diseases, musculoskeletal diseases, and cancer. Copyright © 2016 John Wiley & Sons, Ltd.

Assessing disruptions in adherence to antidepressant treatments after breast cancer diagnosis

PURPOSE

Long-term treatment with antidepressants can lessen the symptoms of depression, but health-related crises-such as a cancer diagnosis-may disrupt ongoing depression care. The study aims to estimate the effect of receiving a breast cancer diagnosis on antidepressant adherence among women with depression.

METHODS

Using SEER-Medicare administrative claims, we identified women aged 65+ with newly diagnosed breast cancer between 2008 and 2011, who were diagnosed with depression and used antidepressants during the year before pre-diagnosis year. We compared antidepressant adherence among women with breast cancer to similar women without cancer using generalized estimation equations. Antidepressant adherence was estimated using the proportion of days covered 1 year before and after the index date.

RESULTS

We included 1142 women with breast cancer and pre-existing depression and 1142 matched non-cancer patients with pre-existing depression. Mean antidepressant adherence was similar for both groups in the year before and after the index date (all around 0.71); adherence decreased by approximately 0.01 following breast cancer diagnosis in cancer group, with similar reductions among non-cancer group (p = 0.19). However, substantial proportion of patients had inadequate adherence to antidepressants in the post-diagnosis period, and almost 40% of patients in each group discontinued antidepressants over the study period.

CONCLUSIONS

Antidepressant adherence was not associated with receiving a breast cancer diagnosis beyond what would have been expected in a similar cohort of women without cancer; however, adherence was poor among both groups. Ensuring adequate ongoing depression care is important to improve cancer care and patient quality of life in the long term. Copyright © 2017 John Wiley & Sons, Ltd.

The clinical and cost effectiveness of cognitive behavioural therapy plus treatment as usual for the treatment of depression in advanced cancer (CanTalk): study protocol for a randomised controlled trial

Background

The prevalence of depressive disorder in adults with advanced cancer is around 20 %. Although cognitive behavioural therapy (CBT) is recommended for depression and may be beneficial in depressed people with cancer, its use for depression in those with advanced disease for whom cure is not likely has not been explored.

Methods

People aged 18 years and above with advanced cancer attending General Practitioner (GP), oncology or hospice outpatients from centres across England will be screened to establish a DSM-IV diagnosis of depression. Self-referral is also accepted. Eligible consenters will be randomised to a single blind, multicentre, randomised controlled trial of the addition to treatment as usual (TAU) of up to 12 one-hour weekly sessions of manualised CBT versus TAU alone. Sessions are delivered in primary care through Increasing Access to Psychological Care (IAPT) service, and the manual includes a focus on issues for people approaching the end of life. The main outcome is the Beck Depression Inventory-II (BDI-II). Subsidiary measures include the Patient Health Questionnaire, quality of life measure EQ-5D, Satisfaction with care, Eastern Cooperative Oncology Group-Performance Status and a modified Client Service Receipt Inventory. At 90 % power, we require 240 participants to enter the trial. Data will be analysed using multi-level (hierarchical) models for data collected at baseline, 6, 12, 18 and 24 weeks. Cost effectiveness analysis will incorporate costs related to the intervention to compare overall healthcare costs and QALYs between the treatment arms. We will conduct qualitative interviews after final follow-up on patient and therapist perspectives of the therapy.

Discussion

This trial will provide data on the clinical and cost effectiveness of CBT for people with advanced cancer and depression. We shall gain an understanding of the feasibility of delivering care to this group through IAPT. Our findings will provide evidence for policy-makers, commissioners and clinicians in cancer and palliative care, and in the community.

Trial registration

Controlled Trials ISRCTN07622709, registered 15 July 2011.

Comparison of cognitive behavioral therapy and supportive psychotherapy for the treatment of depression following traumatic brain injury: a randomized controlled trial

OBJECTIVE

To determine the efficacy of 2 different interventions (cognitive behavioral therapy [CBT] and supportive psychotherapy [SPT]) to treat post-traumatic brain injury (TBI) depression.

PARTICIPANTS

A sample of 77 community-dwelling individuals with a TBI, and a diagnosis of depression. Participants were randomized into treatment conditions either CBT or SPT and received up to 16 sessions of individual psychotherapy.

MEASURES

Participants completed the Structured Clinical Interview for DSM-IV and self-report measures of depression (Beck Depression Inventory-Second Edition), anxiety (State-Trait Anxiety Inventory), perceived social support (Interpersonal Support Evaluation List), stressful life events (Life Experiences Survey), and quality of life (QOL) before beginning and immediately following treatment.

RESULTS

No significant differences were found at baseline between CBT and SPT groups on demographic factors (sex, age, education, race, and time since injury) or baseline measures of depression, anxiety, participation, perceived social support, stressful life events, or QOL. Analyses of variance revealed significant time effects for the Beck Depression Inventory-Second Edition, State-Trait Anxiety Inventory, and QOL outcome measures but no group effects. Intention-to-treat mixed effects analyses did not find any significant difference in patterns of scores of the outcome measures between the CBT and SPT intervention groups.

CONCLUSIONS

Both forms of psychotherapy were efficacious in improving diagnoses of depression and anxiety and reducing depressive symptoms. These findings suggest that in this sample of individuals with TBI, CBT was not more effective in treating depression than SPT, though further research is needed with larger sample sizes to identify different components of these interventions that may be effective with different TBI populations. ClinicalTrials.gov Identifier: NCT00211835.

Enhanced External Counterpulsation Is an Effective Treatment for Depression in Patients With Refractory Angina Pectoris

OBJECTIVE

To examine the effect of enhanced external counterpulsation (EECP) on depression in patients with refractory angina pectoris (Canadian Cardiovascular Society class 2-4).

METHOD

The study was a prospective observational investigation with a 2-month control period preceding the EECP therapy (to minimize a possible effect of the regression-toward-the-mean phenomenon). The patients were examined 2 months before and just before EECP and just after, 3 months after, and 12 months after EECP. Depression was assessed using the Major Depression Inventory and the ICD-10. During EECP, 3 sets of cuffs were fastened around the lower extremities and were inflated sequentially to a pressure of 260 mm Hg in each diastole for 60 minutes 5 days a week for 7 weeks (35 sessions). The study was conducted at a regional hospital in Denmark from May 2006 to January 2011.

RESULTS

Fifty patients with angina pectoris and an abnormal coronary angiography, with no possibility for revascularization, were included (72% men, mean age of 63 years) between May 2006 and January 2011. The prevalence of depression before EECP was 18%, just after was 2%, 3 months after was 2%, and 12 months after was 4% (P = .013). The depressive state was more severe at a lower age (P = .016). No significant predictors of effect of EECP on depression were found (P > .05), and no association was detected between decline in depressive state and chest pain (P > .05).

CONCLUSIONS

The study indicates that EECP is an effective treatment for depression in patients with refractory angina pectoris, that depression is more severe in younger patients, and that the effect of EECP on depression is not related to the effect on chest pain.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01112163.

Effects of Fatty Acid Amide Hydrolase (FAAH) Inhibitors in Non-Human Primate Models of Nicotine Reward and Relapse

Inhibition of the enzyme fatty acid amide hydrolase (FAAH) counteracts reward-related effects of nicotine in rats, but it has not been tested for this purpose in non-human primates. Therefore, we studied the effects of the first- and second-generation O-arylcarbamate-based FAAH inhibitors, URB597 (cyclohexyl carbamic acid 3'-carbamoyl-3-yl ester) and URB694 (6-hydroxy-[1,1'-biphenyl]-3-yl-cyclohexylcarbamate), in squirrel monkeys. Both FAAH inhibitors: (1) blocked FAAH activity in brain and liver, increasing levels of endogenous ligands for cannabinoid and α-type peroxisome proliferator-activated (PPAR-α) receptors; (2) shifted nicotine self-administration dose-response functions in a manner consistent with reduced nicotine reward; (3) blocked reinstatement of nicotine seeking induced by reexposure to either nicotine priming or nicotine-associated cues; and (4) had no effect on cocaine or food self-administration. The effects of FAAH inhibition on nicotine self-administration and nicotine priming-induced reinstatement were reversed by the PPAR-α antagonist, MK886. Unlike URB597, which was not self-administered by monkeys in an earlier study, URB694 was self-administered at a moderate rate. URB694 self-administration was blocked by pretreatment with an antagonist for either PPAR-α (MK886) or cannabinoid CB1 receptors (rimonabant). In additional experiments in rats, URB694 was devoid of THC-like or nicotine-like interoceptive effects under drug-discrimination procedures, and neither of the FAAH inhibitors induced dopamine release in the nucleus accumbens shell--consistent with their lack of robust reinforcing effects in monkeys. Overall, both URB597 and URB694 show promise for the initialization and maintenance of smoking cessation because of their ability to block the rewarding effects of nicotine and prevent nicotine priming-induced and cue-induced reinstatement.

Antidepressant-like effects of magnesium lithospermate B in a rat model of chronic unpredictable stress

CONTEXT

Magnesium lithospermate B (MLB), an active polyphenol acid of Danshen [Radix Salviae miltiorrhizae (Labiatae)], shows neuroprotective and anti-inflammatory effects in vivo and in vitro.

OBJECTIVE

We hypothesized that MLB might exert antidepressant-like effects by targeting the neuroinflammatory signals.

MATERIALS AND METHODS

Sprague-Dawley rats were subjected to the chronic unpredictable stress (CUS) protocol. Rats in the control group received no CUS during the whole experiment. In the model group, rats were exposed to CUS for 7 weeks. From the beginning of the 5th week, model group rats were randomly grouped and subjected to different treatments. In the experiment, control and model group rats were intraperitoneally (i.p.) injected with saline. MLB was dissolved in saline to give a final concentration, and the rats were injected (i.p.) with 15, 30, or 60 mg/kg MLB once a day for 3 weeks.

RESULTS

MLB administration significantly reduced: (1) the immobility time in the forced swimming test (19 s, p < 0.05); (2) the immobility time in the tail suspension test (76.3 s, p < 0.05); (3) the corticosterone (CORT) concentrations in the serum (21.7 nmol/L, p > 0.05); (4) the pro-inflammatory cytokine levels in the serum - TNF-α (92.1 pg/ml, p < 0.05), IL-1β (86.9 pg/ml, p < 0.05), and IL-6 (93.8 pg/ml, p < 0.05); (5) pro-inflammatory cytokine levels in tissue - TNF-α (3.2 pg/mg protein, p < 0.05), IL-1β (1.5 pg/mg protein, p > 0.05), and IL-6 (6.3 pg/mg protein, p < 0.05); and (6) phospho-NF-κB (1.6, p < 0.05) and phospho-IκB-α (0.4, p < 0.05) expression in tissue.

DISCUSSION AND CONCLUSION

The results suggested that MLB might exert therapeutic actions on depression-like behavior and the HPA axis hyperactivity in CUS rats, and the mechanisms underlying the antidepressant-like effects of MLB might be mediated by regulation of the expression of NF-κB and IκB-α in rats.

Treatment of affective disorders in cardiac disease

Patients with cardiovascular disease (CVD) commonly have syndromal major depression, and depression has been associated with an increased risk of morbidity and mortality. Prevalence of depression is between 17% and 47% in CVD patients. Pharmacologic and psychotherapeutic interventions have long been studied, and in general are safe and somewhat efficacious in decreasing depressive symptoms in patients with CVD. The impact on cardiac outcomes remains unclear. The evidence from randomized controlled clinical trials indicates that antidepressants, especially selective serotonin uptake inhibitors, are overwhelmingly safe, and likely to be effective in the treatment of depression in patients with CVD. This review describes the prevalence of depression in patients with CVD, the physiological links between depression and CVD, the treatment options for affective disorders, and the clinical trials that demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population. Great progress has been made in understanding potential mediators between major depressive disorder and CVD—both health behaviors and shared biological risks such as inflammation.

Chronic physical comorbidity burden and the quality of depression treatment in primary care: a systematic review

OBJECTIVE

We examined whether the treatment and follow-up care for depression in routine primary care differs between adults with higher chronic physical comorbidity burden compared to adults with lower chronic physical comorbidity burden and explored factors leading to divergent results across studies.

METHODS

We conducted a systematic review of English and French articles using Medline, Embase, PsycINFO, CINAHL and Cochrane Controlled Trials Register from inception to July 2013. Reference list and reverse citation searches were also conducted. Search terms included depression, primary care, general practitioner, chronic disease and comorbidity. Study eligibility required inclusion of relevant quality indicators and data contrasting participants with higher and lower chronic physical comorbidity burden. Study selection and quality appraisal were carried out independently by two review authors. A narrative synthesis of results was performed.

RESULTS

Our search yielded 5817 unique citations and 46 studies met inclusion criteria. Studies provided data on quality of pharmacotherapy (n=28), psychotherapy (n=4), combined measures of treatment quality (n=14), and follow-up care (n=9). Across studies, evidence that higher chronic physical comorbidity burden was associated with lower depression treatment or follow-up care quality was reported in 13 studies whereas evidence for the opposite relationship was reported in 15 studies. Four studies reported mixed results and 14 studies observed no relationships between comorbidity burden and depression treatment or follow-up care quality.

CONCLUSION

Review findings suggest that chronic physical comorbidity does not consistently lead to lower quality of depression treatment or follow-up care in primary care.

Depression and pain: an appraisal of cost effectiveness and cost utility of antidepressants

BACKGROUND

Although depression and chronic pain frequently co-occur, there is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants in the presence of these two conditions. From the perspective of healthcare provider, the current study aims to compare the cost-effectiveness and cost-utility of antidepressants in a national cohort of depressed patients with and without comorbid pain conditions.

METHODS

Adult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan (n=96,501). By using remission as effectiveness measure and quality-adjusted life years (QALYs) as utility measure, the cost-effectiveness and cost-utility were compared across selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), as well as by the presence of comorbid painful physical symptoms (PPS).

RESULTS

SSRIs dominated SNRIs in both the cost-effectiveness and cost-utility regardless of comorbid PPS. In comparison with TCAs, SSRIs were likely to be the cost-effective option for patients without PPS. In patients with PPS, the cost-utility advantage for SSRIs over TCAs varied with threshold willingness-to-pay levels. Comorbid PPS may be considered an effect modifier of the cost-utility comparisons between SSRIs and TCAs.

CONCLUSIONS

For depressed patients without PPS, SSRIs are likely to be cost-effective in improving remission rates and QALYs compared to TCAs and SNRIs. However, to improve cost-utility in those with comorbid PPS, people need to choose between SSRIs and TCAs according to threshold willingness-to-pay levels. Future research is warranted to clarify the impacts of different pain conditions on the economic evaluations of pharmacological treatments in patients with depression.

Depression in Older Adults in Primary Care

Depression in older adults is a problem often encountered in primary care. While depression is evident in all populations in the primary care setting, assessment and care are more complicated in the older adult due to factors such as comorbidities, clinical presentation, adverse drug effects and drug interactions, and psychosocial factors. Due to these complications, it is essential to incorporate both conventional and alternative methods in assessment and treatment. This article aims to define depression in older adults, present the epidemiology, discuss clinical presentation and screening, and offer an integrative approach to intervention, including both pharmacological and nonpharmacological methods. Providing holistic and integrative care to older adults diagnosed with depression in the primary care setting is essential to promote healing and recovery. This article aims to provide insight for nurses, nurse practitioners, and other providers regarding the holistic and integrative care of depression in older adults in the primary care setting.

Scientific hypotheses can be tested by comparing the effects of one treatment over many diseases in a systematic review

OBJECTIVES

To describe the use of systematic reviews or overviews (systematic reviews of systematic reviews) to synthesize quantitative evidence of intervention effects across multiple indications (multiple-indication reviews) and to highlight issues pertaining to such reviews.

STUDY DESIGN AND SETTING

MEDLINE was searched from 2003 to January 2014. We selected multiple-indication reviews of interventions of allopathic medicine that included evidence from randomized controlled trials. We categorized the subject areas evaluated by these reviews and examined their methodology. Utilities and caveats of multiple-indication reviews are illustrated with examples drawn from published literature.

RESULTS

We retrieved 52 multiple-indication reviews covering a wide range of interventions. The method has been used to detect unintended effects, improve precision by pooling results across indications, and examine scientific hypotheses across disease classes.

CONCLUSION

Systematic reviews of interventions are typically used to evaluate the effects of treatments, one indication at a time. Here, we argue that, with due attention to methodological caveats, much can be learned by comparing the effects of a given treatment across many related indications.

Integrated management of major depression for people with cancer

Major depression is an important complication of cancer. However, it is frequently inadequately treated. There are challenges both in identifying which cancer patients are depressed, and in ensuring that these patients receive effective treatment for their depression. Integration of depression management into cancer care has been advocated as a way to address these challenges. Such integrated approaches must include both the systematic identification of cases and the delivery of treatment. We describe here a system of depression care that includes both a screening programme to identify patients with depression and a linked treatment programme, based on the collaborative care model, called 'Depression Care for People with Cancer' (DCPC). The system of care was designed to be fully integrated with specialist cancer services and has been robustly evaluated in randomized trials. We describe how the system operates and explain why it is designed as it is. We also summarize the evidence for its effectiveness and cost-effectiveness and discuss its implementation in routine clinical practice.

Reevaluating the role of antidepressants in cancer-related depression: a systematic review and meta-analysis

OBJECTIVE

Prior reviews evaluating the role of antidepressants in cancer-related depression have drawn conflicting conclusions. These reviews have also not explored differences in efficacy and tolerability between antidepressants. We conducted a meta-analysis to address these limitations.

METHOD

We searched Medline (1948-2013), the Cochrane Library (1800-2013), the Cumulative Index to Nursing and Allied Health Literature (1986-2013), ClinicalTrials.gov (2013) and meeting abstracts. We included randomized trials comparing antidepressants to placebo or no treatment for cancer-related depression. We used random effects to calculate standardized mean differences (SMD).

RESULTS

Of 5178 potentially eligible citations, 9 trials (1169 subjects) met inclusion criteria. Trials of mianserin found a robust reduction in depression scores at ≥4 weeks of treatment (SMD: 0.60, 95% confidence interval (CI): 0.24-0.95). Similar, but less robust, results were observed with paroxetine (SMD: 0.22, 95% CI: 0.01-0.42) and fluoxetine (SMD 0.34, 95% CI: 0.02-0.66). Conversely, there was no advantage with amitriptyline or desipramine. Compared to placebo, the odds of dropping out due to side effect were higher with fluoxetine and paroxetine and lower with mianserin. Methodological quality was moderate.

CONCLUSIONS

Paroxetine, fluoxetine and mianserin improve cancer-related depression but may vary in efficacy and tolerability. High-quality, randomized trials of newer antidepressant agents are needed to identify optimal treatments for managing cancer-related depression.

Cost-effectiveness and cost-utility of selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants in depression with comorbid cardiovascular disease

OBJECTIVE

There is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants for treating real-world patients. The impact of comorbid cardiovascular disease (CVD) on the economic evaluations of antidepressants remains to be determined.

METHOD

Adult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan. A cost-effectiveness and cost-utility analysis was conducted comparing selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), and by the presence of comorbid CVD.

RESULTS

In terms of treatment success rates, SSRIs were the most cost-effective option compared to TCAs and SNRIs as revealed in the incremental cost-effectiveness ratios. The cost-effectiveness acceptability curves further showed differential findings in the cost-utility results by the presence of comorbid CVD.

CONCLUSION

To improve treatment success rates and quality-adjusted life years, SSRIs can be considered the most cost-effective option. Future research is needed to further clarify the impacts of physical comorbidities and other associated factors on the cost-effectiveness and cost-utility of pharmacological treatments in patients with depression.

Negative and positive beliefs related to mood and health

OBJECTIVES

To observe whether elderly patients' positive and negative beliefs about efforts improving or maintaining health are related to health and mood.

METHODS

We developed a brief scale to assess these beliefs. Factor analysis was used to evaluate its dimensions; the extent to which the scale's dimensions mediate the relationship between mood and self-reported health was explored.

RESULTS

Analyses show that the scale reflects a general factor as well as 2 subscales that evaluate distinct but related positive and negative dimensions. The scale was not related to race, sex, or education, but showed modest relations to age. Scales were significantly related to mood, health status, and health-related quality of life.

CONCLUSIONS

Both negative and positive beliefs mediated the relation between depression and self-reported health.

Prescribing selective serotonin reuptake inhibitors in older age

Apart from commercial reasons, two motivations have led to the introduction of SSRIs to replace the first and second generation antidepressants already available. One was the search for a more rational treatment, based on specific mechanisms, the other the development of effective treatments with fewer side effects, particularly for older patients, who have a greater sensitivity to cardio-vascular and central nervous system effects. The first has been frustrated up to a point, in that SSRIs and other single mechanism drugs do not appear to be more effective than the earliest relatively non-specific antidepressants. The second has been fulfilled, in that SSRIs generally are better tolerated in older patients and in overdose. However, there is a spectrum of other side effects that are particularly relevant in older age and that need attention when treating depression in this particular patient group.

What is the role of medications in late life depression?

In this article, the efficacy and side effects of antidepressants in the elderly are discussed. In addition, whether the elderly in general should be treated with lower doses of antidepressants, and whether the elderly have a slower response to antidepressant treatment, are also discussed.

Antidepressant medication in patients with advanced cancer--an observational study

OBJECTIVE

Literature reviews suggest limited evidence of efficacy of antidepressant medication in patients with advanced cancer. This study was carried out to observe the longitudinal effect of antidepressant medication in a cohort of advanced cancer patients.

METHOD

Patients were recruited from hospice day care settings and followed up longitudinally by series of measures for depression for 6 months or until death.

RESULTS

Six hundred and twenty nine patients recruited. One hundred and fifty six patients in total (25%) were receiving antidepressant medication for a median of 9.5 weeks (range 0-36 weeks) and a mean of 12.2 weeks. There was no significant difference in scores on depression measures over time for patients receiving antidepressant medication.

CONCLUSION

Antidepressant medication for advanced cancer patients appeared to have little impact on depression scores. We postulate the holistic approaches within hospice day care may in themselves be interventions for depression thereby masking effect of pharmacological treatment. Further research should explore multi-intervention models for management of depression in advanced cancer.

Transcranial direct current stimulation and repetitive transcranial magnetic stimulation in consultation-liaison psychiatry

Patients with clinical diseases often present psychiatric conditions whose pharmacological treatment is hampered due to hazardous interactions with the clinical treatment and/or disease. This is particularly relevant for major depressive disorder, the most common psychiatric disorder in the general hospital. In this context, nonpharmacological interventions could be useful therapies; and, among those, noninvasive brain stimulation (NIBS) might be an interesting option. The main methods of NIBS are repetitive transcranial magnetic stimulation (rTMS), which was recently approved as a nonresearch treatment for some psychiatric conditions, and transcranial direct current stimulation (tDCS), a technique that is currently limited to research scenarios but has shown promising results. Therefore, our aim was to review the main medical conditions associated with high depression rates, the main obstacles for depression treatment, and whether these therapies could be a useful intervention for such conditions. We found that depression is an important and prevalent comorbidity in a variety of diseases such as epilepsy, stroke, Parkinson's disease, myocardial infarction, cancer, and in other conditions such as pregnancy and in patients without enteral access. We found that treatment of depression is often suboptimal within the above contexts and that rTMS and tDCS therapies have been insufficiently appraised. We discuss whether rTMS and tDCS could have a significant impact in treating depression that develops within a clinical context, considering its unique characteristics such as the absence of pharmacological interactions, the use of a nonenteral route, and as an augmentation therapy for antidepressants.

Major depressive disorder in breast cancer: a critical systematic review of pharmacological and psychotherapeutic clinical trials

BACKGROUND

While women with breast cancer often face varying levels of psychological distress, there is a subgroup whose symptomatology reaches a threshold for diagnosis of major depressive disorder (MDD). Major depressive disorder is known to influence patient outcomes, such as health-related quality of life and treatment adherence. There are no systematic reviews that evaluate pharmacological and psychotherapeutic treatment trials for MDD among individuals with breast cancer.

METHODS

Two authors independently searched MEDLINE, EMBASE, Cochrane and Clinical Trials.gov databases through February 20, 2013 without language restrictions. Core journals, reference lists and citation tracking were also searched. Articles on breast cancer patients were included if they (1) included participants with a diagnosis of MDD; (2) investigated pharmacological or psychotherapeutic treatments for MDD compared to placebo or usual care in a randomized controlled trial (RCT).

RESULTS

Two RCTs on antidepressant treatment met inclusion criteria. However, no RCTs investigating the effects of psychological treatments for MDD in breast cancer were identified. Notwithstanding the paucity of data investigating the effects of psychological treatments for MDD in breast cancer, numerous psychotherapeutic strategies targeting depressive symptoms were identified. Mianserin had significant antidepressant effects when compared to placebo in a 6-week, parallel-group, RCT of Stage I-II breast cancer in women with MDD. Desipramine and paroxetine were reported to be no more efficacious than placebo in a 6-week, RCT of Stage I-IV breast cancer in women with MDD.

CONCLUSIONS

The evidence reviewed herein underscores the paucity of data available to guide clinicians in treatment decisions for MDD in individuals with breast cancer. Therefore, the treatment of MDD in breast cancer is primarily based on clinical experience. Some antidepressants (for example, paroxetine) should be avoided in women concurrently taking tamoxifen due to relevant interactions involving the cytochrome CYP2D6.

Antidepressant-like effects of lycii radicis cortex and betaine in the forced swimming test in rats

The purpose of the present study was to examine the effect of Lycii Radicis Cortex (LRC) and betaine (BT) on immobility and neurochemical change in the forced swimming test (FST) in the rat. LRC, BT or fluoxentine was administered intraperitoneally to Sprague-Dawley rats three times (1, 5 and 23.5 h) before the FST. To investigate antidepressant-like effect, serotonin (5-HT) and norepinephrine (NE) were examined in the hippocampus and hypothalamus of rats. LRC (100 mg/kg) and BT (30, 100 mg/kg) significantly decreased the immobility time in the FST. LRC (100 mg/kg) significantly increased both 5-HT and NE levels in the hypothalamus of rats exposed to FST. BT (100 mg/kg) significantly increased 5-HT levels in the hypothalamus and hippocampus of rats. Taken together, these results demonstrated that improvement in the behavioral changes after LRC and BT administration may be mediated by elevation of 5-HT level in the hypothalamus and hippocampus, indicating a possible antidepressant-like activity. The present results suggest that the efficacy of LRC and BT in an animal model of depression may provide anti-depressant effects in human, which remains to be determined.

Depression as a risk factor for adverse outcomes in coronary heart disease

BACKGROUND

Depression is firmly established as an independent predictor of mortality and cardiac morbidity in patients with coronary heart disease (CHD). However, it has been difficult to determine whether it is a causal risk factor, and whether treatment of depression can improve cardiac outcomes. In addition, research on biobehavioral mechanisms has not yet produced a definitive causal model of the relationship between depression and cardiac outcomes.

DISCUSSION

Key challenges in this line of research concern the measurement of depression, the definition and relevance of certain subtypes of depression, the temporal relationship between depression and CHD, underlying biobehavioral mechanisms, and depression treatment efficacy.

SUMMARY

This article examines some of the methodological challenges that will have to be overcome in order to determine whether depression should be regarded as a key target of secondary prevention in CHD.

Antidepressants for depression in Parkinson's disease: systematic review and meta-analysis

Depression is common in Parkinson's disease (PD) and is associated with several poor outcomes. However the literature regarding treatment with antidepressants in this population is controversial. The aim of this paper was to systematically review all randomized controlled trials that studied the efficacy of antidepressants for depression in PD (dPD). Studies were retrieved from PubMed (1966-July 2012), Cochrane Library (-July 2012, issue 7), Embase (1980-July 2012), PsycINFO (1980-July 2012), Lilacs (1982-July 2012), secondary references, clinical trials registries and a thesis database. Only double-blind, randomized controlled trials in which an antidepressant was given as the main treatment and compared with placebo and/or another antidepressant were included. Out of the 1438 studies retrieved, only six could be included. Taking into account the five placebo-controlled trials, the overall risk ratio (RR) for response was 1.36 (0.98, 1.87), indicating no statistically significant superiority of antidepressants over placebo. However, in the sensitivity analysis, the RR for response was 1.41 (1.01, 1.96) and 1.48 (1.05, 2.10) after exclusion of one study with questionable results, and when only studies with low risk of bias were considered, respectively. No specific antidepressant class was superior to placebo. In general antidepressant medications were well tolerated. The results suggest antidepressants may be efficacious in the treatment of dPD. However, the results were unstable. In fact, the small number of trials and methodological drawbacks preclude definitive conclusions about their efficacy and tolerability in dPD.

Physical comorbidities in men with mood and anxiety disorders: a population-based study

BACKGROUND

The mind-body nexus has been a topic of growing interest. Further data are however required to understand the specific relationship between mood and anxiety disorders and individual physical health conditions, and to verify whether these psychiatric disorders are linked to overall medical burden.

METHODS

This study examined data collected from 942 men, 20 to 97 years old, participating in the Geelong Osteoporosis Study. A lifetime history of mood and anxiety disorders was identified using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID-I/NP). The presence of medical conditions (lifetime) was self-reported and confirmed by medical records, medication use or clinical data. Anthropometric measurements and socioeconomic status (SES) were determined and information on medication use and lifestyle was obtained via questionnaire. Logistic regression models were used to test the associations.

RESULTS

After adjustment for age, socioeconomic status, and health risk factors (body mass index, physical activity and smoking), mood disorders were associated with gastro oesophageal reflux disease (GORD), recurrent headaches, blackouts and/or epilepsy, liver disorders and pulmonary disease in older people, whilst anxiety disorders were significantly associated with thyroid, GORD and other gastrointestinal disorders, and psoriasis. Increased odds of high medical burden were associated with both mood and anxiety disorders.

CONCLUSIONS

Our study provides further population-based evidence supporting the link between mental and physical illness in men. Understanding these associations is not only necessary for individual management, but also to inform the delivery of health promotion messages and health care.

Diagnosis and Treatment of Depression Following Traumatic Brain Injury

Depression is one of the most common psychiatric diagnoses among individuals with traumatic brain injury (TBI). Prevalence of post-TBI depression (PTBID) ranges from 12 to 60% and is generally higher than rates reported in the general population. The wide range in reported rates is attributed to methodological variability across studies, including measurement and sampling differences. Several systematic reviews have been published in the past 5 years, reporting on outcomes for depression across different classes of interventions, including pharmacological, biomedical and behavioural. The consensus across reviews is that more research is necessary to develop evidence-based practice guidelines. The present narrative review synthesises the findings of previous studies, focusing on the nature of the interventions, the eligibility criteria for inclusion and the assessment of outcome. Pharmacological studies are generally more rigorous methodologically, but provide mixed findings. Other biomedical interventions are only at the initial stages of research development, including case and pilot studies. The results of behavioural studies are positive regarding improvements in mood. However, the number of efficacy studies of behavioural interventions for depression is extremely limited. Recommendations for designing interventions are provided.

Treatment of depression in cardiovascular disease

BACKGROUND AND OBJECTIVES

Depression in patients with Cardiovascular Disease (CVD) is extremely common, with a prevalence of 17-47%, and is associated with increased risk of morbidity and mortality. Treatment of depression has been hypothesized to reduce cardiac mortality. Pharmacologic and psychotherapeutic interventions have been studied and appear to be safe and in some studies effective in reducing depressive symptoms in patients with cardiac disease. The impact on cardiac outcomes remains unclear. This review briefly focuses on the prevalence of depression in patients with CVD, the physiological links between depression and CVD, and largely is concerned with the clinical trials that seek to demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population.

METHODS

PubMed and PsycINFO databases were searched through July 2012. Publications were included if they were in English, a review article, or a clinical trial in the CVD population with comorbid depression. The search was completed with key words of antidepressants, CVD, coronary artery syndrome, SSRIs, depression, treatment of depression, post-MI (where MI is myocardial infarction), major depression, and cardiac disease. Trials were included if the patients were above the age of 18, both male and female genders, and had cardiac comorbidity. No trials were excluded.

RESULTS

A total of 61 articles and/or book chapters were included. The majority were from North America and Europe. There were 7 clinical trials of tricyclic antidepressants (TCAs), one of TCAs and bupropion, and 10 trials of selective serotonin reuptake inhibitors (SSRIs). We also evaluated five trials involving psychotherapeutic techniques and/or collaborative care.

CONCLUSIONS

There is considerable evidence from randomized controlled clinical trials that antidepressants, especially SSRIs, are safe in the treatment of major depression in patients with CVD. Although efficacy has been demonstrated in some, but not all, trials for both antidepressants and certain psychotherapies, large, well-powered trials are urgently needed. There are virtually no data available on predictors of antidepressant response in depressed patients with CVD. Whether successful treatment of depression is associated with a reduction in cardiac morbidity and mortality remains unknown.

Inhibition of FAAH and activation of PPAR: new approaches to the treatment of cognitive dysfunction and drug addiction

Enhancing the effects of endogenously-released cannabinoid ligands in the brain might provide therapeutic effects more safely and effectively than administering drugs that act directly at the cannabinoid receptor. Inhibitors of fatty acid amide hydrolase (FAAH) prevent the breakdown of endogenous ligands for cannabinoid receptors and peroxisome proliferator-activated receptors (PPAR), prolonging and enhancing the effects of these ligands when they are naturally released. This review considers recent research on the effects of FAAH inhibitors and PPAR activators in animal models of addiction and cognition (specifically learning and memory). These studies show that FAAH inhibitors can produce potentially therapeutic effects, some through cannabinoid receptors and some through PPAR. These effects include enhancing certain forms of learning, counteracting the rewarding effects of nicotine and alcohol, relieving symptoms of withdrawal from cannabis and other drugs, and protecting against relapse-like reinstatement of drug self-administration. Since FAAH inhibition might have a wide range of therapeutic actions but might also share some of the adverse effects of cannabis, it is noteworthy that at least one FAAH-inhibiting drug (URB597) has been found to have potentially beneficial effects but no indication of liability for abuse or dependence. Although these areas of research are new, the preliminary evidence indicates that they might lead to improved therapeutic interventions and a better understanding of the brain mechanisms underlying addiction and memory.

Validation of the Whooley questions and the Beck Depression Inventory in older adults

OBJECTIVE

To analyse the psychometric properties of the Whooley questions and the 21-item Beck Depression Inventory (BDI-21) in older adults with depression and chronic health problems.

DESIGN

A population-based study.

SETTING

Community.

SUBJECTS

474 adults, aged 72-73 years, living in the city of Oulu, Finland.

MAIN OUTCOME MEASURES

The screening parameters of the Whooley questions and the BDI-21 for detecting major depression.

RESULTS

The prevalence of major depression according to the DSM-IV was 5.3% (single or recurrent episode) obtained by the Mini Neuropsychiatric Interview (MINI). The BDI-21 was best able to identify a current episode of major depression with a cut-off point of 11. The sensitivity and specificity of this cut-off point were 88.0% (95% confidence interval (95% CI) 68.8-97.5) and 81.7% (95% CI 77.8-85.2), respectively. The area under the receiver operating characteristics (ROC) curve was 0.89 (95% CI 0.83-0.96). The two Whooley screening questions had a sensitivity of 62.5% (95% CI 40.6-81.2) and either screening question plus the help question had a sensitivity of 66.7% (44.7-84.4).

CONCLUSIONS

The Beck Depression Inventory is a valid instrument for the diagnosis of depression in older adults. As a screening measure, the optimal cut-off score should be 11 or higher. Our results indicate that the sensitivity of the Whooley questions is not high enough to be used as a screening scale among the elderly.

Effect of exercise on depression severity in older people: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The prevalence of depression in older people is high, treatment is inadequate, it creates a substantial burden and is a public health priority for which exercise has been proposed as a therapeutic strategy.

AIMS

To estimate the effect of exercise on depressive symptoms among older people, and assess whether treatment effect varies depending on the depression criteria used to determine participant eligibility.

METHOD

Systematic review and meta-analysis of randomised controlled trials of exercise for depression in older people.

RESULTS

Nine trials met the inclusion criteria and seven were meta-analysed. Exercise was associated with significantly lower depression severity (standardised mean difference (SMD) = -0.34, 95% CI -0.52 to -0.17), irrespective of whether participant eligibility was determined by clinical diagnosis (SMD = -0.38, 95% CI -0.67 to -0.10) or symptom checklist (SMD = -0.34, 95% CI -0.62 to -0.06). Results remained significant in sensitivity analyses.

CONCLUSIONS

Our findings suggest that, for older people who present with clinically meaningful symptoms of depression, prescribing structured exercise tailored to individual ability will reduce depression severity.