General health, health care utilization, and medical comorbidity in dysthymia

Effects of the antidepressant medication duloxetine on brain metabolites in persistent depressive disorder: A randomized, controlled trial

Background

To assess whether patients with Persistent Depressive Disorder (PDD) have abnormal levels of N-acetyl-aspartate (NAA) and whether those levels normalize following treatment with the antidepressant medication duloxetine. Furthermore, we conducted post hoc analyses of other important brain metabolites to understand better the cellular and physiological determinants for changes in NAA levels.

Methods

We acquired proton (1H) magnetic resonance spectroscopic imaging (MRSI) data on a 3 Tesla (3T), GE Magnetic Resonance Imaging (MRI) scanner in 41 patients (39.9±10.4 years, 22 males) with PDD at two time points: before the start and at the end of a 10-week, placebo-controlled, double-blind, randomized controlled trial (RCT) of the antidepressant medication duloxetine. Patients were randomized such that 21 patients received the active medication and 20 patients received placebo during the 10 week period of the trial. In addition, we acquire 1H MRSI data once in 29 healthy controls (37.7±11.2 years, 17 males).

Findings

Patients had significantly higher baseline concentrations of NAA across white matter (WM) pathways and subcortical gray matter, and in direct proportion to the severity of depressive symptoms. NAA concentrations declined in duloxetine-treated patients over the duration of the trial in the direction toward healthy values, whereas concentrations increased in placebo-treated patients, deviating even further away from healthy values. Changes in NAA concentration did not mediate medication effects on reducing symptom severity, however; instead, changes in symptom severity partially mediated the effects of medication on NAA concentration, especially in the caudate and putamen.

Interpretation

These findings, taken together, suggest that PDD is not a direct consequence of elevated NAA concentrations, but that a more fundamental pathophysiological process likely causes PDD and determines the severity of its symptoms. The findings also suggest that although duloxetine normalized NAA concentrations in patients, it did so by modulating the severity of depressive symptoms. Medication presumably reduced depressive symptoms through other, as yet unidentified, brain processes.

Trial registration

ClinicalTrials.gov NCT00360724.

Methylene Blue: The Long and Winding Road From Stain to Brain: Part 2

Methylene blue was the first synthetic drug ever used in medicine, having been used to treat clinical pain syndromes, malaria, and psychotic disorders more than one century ago. Methylene blue is a cationic thiazine dye with redox-cycling properties and a selective affinity for the nervous system. This drug also inhibits the activity of monoamine oxidase, nitric oxide synthase, and guanylyl cyclase, as well as tau protein aggregation; increases the release of neurotransmitters, such as serotonin and norepinephrine; reduces amyloid-beta levels; and increases cholinergic transmission. The action of methylene blue on multiple cellular and molecular targets justifies its investigation in various neuropsychiatric disorders. Investigations of methylene blue were instrumental in the serendipitous development of phenothiazine antipsychotic drugs. Although chlorpromazine is heralded as the first antipsychotic drug used in psychiatry, methylene blue is a phenothiazine drug that had been used to treat psychotic patients half a century earlier. It has also been studied in bipolar disorder and deserves further investigation for the treatment of unipolar and bipolar disorders. More recently, methylene blue has been the subject of preclinical and clinical investigations for cognitive dysfunction, dementia, and other neurodegenerative disorders. [Journal of Psychosocial Nursing and Mental Health Services, 54(10), 21-26.].

Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization

BACKGROUND

Poor psychological and physical resilience in response to stress drives a great deal of health care utilization. Mind-body interventions can reduce stress and build resiliency. The rationale for this study is therefore to estimate the effect of mind-body interventions on healthcare utilization.

OBJECTIVE

Estimate the effect of mind body training, specifically, the Relaxation Response Resiliency Program (3RP) on healthcare utilization.

DESIGN

Retrospective controlled cohort observational study.

SETTING

Major US Academic Health Network.

SAMPLE

All patients receiving 3RP at the MGH Benson-Henry Institute from 1/12/2006 to 7/1/2014 (n = 4452), controls (n = 13149) followed for a median of 4.2 years (.85-8.4 yrs).

MEASUREMENTS

Utilization as measured by billable encounters/year (be/yr) stratified by encounter type: clinical, imaging, laboratory and procedural, by class of chief complaint: e.g., Cardiovascular, and by site of care delivery, e.g., Emergency Department. Subgroup analysis by propensity score matched pre-intervention utilization rate.

RESULTS

At one year, total utilization for the intervention group decreased by 43% [53.5 to 30.5 be/yr] (p <0.0001). Clinical encounters decreased by 41.9% [40 to 23.2 be/yr], imaging by 50.3% [11.5 to 5.7 be/yr], lab encounters by 43.5% [9.8 to 5.6], and procedures by 21.4% [2.2 to 1.7 be/yr], all p < 0.01. The intervention group's Emergency department (ED) visits decreased from 3.6 to 1.7/year (p<0.0001) and Hospital and Urgent care visits converged with the controls. Subgroup analysis (identically matched initial utilization rates-Intervention group: high utilizing controls) showed the intervention group significantly reduced utilization relative to the control group by: 18.3% across all functional categories, 24.7% across all site categories and 25.3% across all clinical categories.

CONCLUSION

Mind body interventions such as 3RP have the potential to substantially reduce healthcare utilization at relatively low cost and thus can serve as key components in any population health and health care delivery system.

Psychiatric comorbidity in diabetes type 1: a cross-sectional observational study

OBJECTIVE

This study aims to investigate the prevalence of psychiatric disorders, i.e., the presence of signs and symptoms of anxiety and depression in type 1 diabetic patients, as well as to investigate the prevalence of psychiatric disorders in insulin dependent patients.

METHODS

A cross-sectional observational study of 110 diabetic outpatients (mean = 58.3, SD = 14.5; 50 male and 60 female) was conducted in a public health clinic with patients diagnosed with diabetes mellitus who were under the medical supervision of an endocrinologist. The patients were evaluated through the Mini International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale(HADS).

RESULTS

With respect to anxiety symptoms, we found a prevalence of 60% (n = 66) among patients, while in depression symptoms we found a prevalence of 53.6% (n = 59) concerning the 110 patients evaluated. More specifically, we found 28.2% (n = 31) of patients without depression or anxiety, 13.6% (n = 15) of patients with depression, 16.4% (n = 18) of patients with anxiety and 41.8% (n = 46) of patients with depression combined with anxiety. The most remarkable data were generalized anxiety disorder (22.7%), dysthymia (18.2%), panic disorder (8.2%) and social phobia (5.5%).

CONCLUSION

The need for accurate assessments about the presence of symptoms related to psychopathology in patients with type 1 diabetes is evident.

An open treatment trial of duloxetine in elderly patients with dysthymic disorder

Objective:

We evaluated the efficacy and side effects of the selective serotonin and norepinephrine reuptake inhibitor antidepressant duloxetine in older adults with dysthymic disorder.

Methods:

Patients ≥ 60 years old with dysthymic disorder received flexible dose duloxetine 20–120 mg daily in an open-label 12-week trial. The main outcomes were change from baseline to 12 weeks in 24-item Hamilton Depression Rating Scale scores and Treatment Emergent Symptoms Scale scores. Response required ≥ 50% decline in Hamilton Depression Rating Scale scores with a Clinical Global Impression of much improved or better, and remission required final Hamilton Depression Rating Scale ≤ 6. Intent-to-treat analyses were conducted with the last observation carried forward.

Results:

In 30 patients, the mean age was 70.7 (standard deviation (SD) = 7.6) years and 56.7% were female. In intent-to-treat analyses, there were 16 responders (53.3%) and 10 remitters (33.3%). Of these, 19 patients completed the trial. The mean maximum dose was 76.3 mg (SD = 38.5) in the total sample and 101 mg (SD = 17.9) in completers. In the total sample, the mean final dose was 51 mg (SD = 27.2) and correlated significantly with decline in Hamilton Depression Rating Scale (p < .03); decline in Hamilton Depression Rating Scale correlated significantly with decline in Treatment Emergent Symptoms Scale (p < .001). Daily doses above 60 mg were associated with greater improvement and well tolerated. This result was partly confounded by early dropouts having received low doses. Demographic and medical comorbidities, including cardiac disease and hypertension, were not related to response. Somatic side effects were common prior to duloxetine treatment and improved rather than worsened with duloxetine. There were no serious adverse events.

Conclusion:

Duloxetine at relatively high doses showed moderate efficacy in elderly patients with dysthymic disorder and was well tolerated in successful completers. Reduced somatic symptoms were associated with improvement in depressive symptoms. A systematic placebo-controlled trial of duloxetine in older patients with dysthymic disorder may be warranted.

Antidepressants normalize the default mode network in patients with dysthymia

IMPORTANCE

The default mode network (DMN) is a collection of brain regions that reliably deactivate during goal-directed behaviors and is more active during a baseline, or so-called resting, condition. Coherence of neural activity, or functional connectivity, within the brain's DMN is increased in major depressive disorder relative to healthy control (HC) subjects; however, whether similar abnormalities are present in persons with dysthymic disorder (DD) is unknown. Moreover, the effect of antidepressant medications on DMN connectivity in patients with DD is also unknown.

OBJECTIVE

To use resting-state functional-connectivity magnetic resonance imaging (MRI) to study (1) the functional connectivity of the DMN in subjects with DD vs HC participants and (2) the effects of antidepressant therapy on DMN connectivity.

DESIGN

After collecting baseline MRI scans from subjects with DD and HC participants, we enrolled the participants with DD into a 10-week prospective, double-blind, placebo-controlled trial of duloxetine and collected MRI scans again at the conclusion of the study. Enrollment occurred between 2007 and 2011.

SETTING

University research institute.

PARTICIPANTS

Volunteer sample of 41 subjects with DD and 25 HC participants aged 18 to 53 years. Control subjects were group matched to patients with DD by age and sex.

MAIN OUTCOME MEASURES

We used resting-state functional-connectivity MRI to measure the functional connectivity of the brain's DMN in persons with DD compared with HC subjects, and we examined the effects of treatment with duloxetine vs placebo on DMN connectivity.

RESULTS

Of the 41 subjects with DD, 32 completed the clinical trial and MRI scans, along with the 25 HC participants. At baseline, we found that the coherence of neural activity within the brain's DMN was greater in persons with DD compared with HC subjects. Following a 10-week clinical trial, we found that treatment with duloxetine, but not placebo, normalized DMN connectivity.

CONCLUSIONS AND RELEVANCE

The baseline imaging findings are consistent with those found in patients with major depressive disorder and suggest that increased connectivity within the DMN may be important in the pathophysiology of both acute and chronic manifestations of depressive illness. The normalization of DMN connectivity following antidepressant treatment suggests an important causal pathway through which antidepressants may reduce depression.

Prevalence of psychiatric disorders in patients with diabetes types 1 and 2

BACKGROUND

Diabetes mellitus, classified into types 1 and 2, is a chronic disease that shows high comorbidity with psychiatric disorders. Insulin-dependent patients show a higher prevalence of psychiatric disorders than do patients with type 2 diabetes.

METHODS

This research involved the participation of 200 subjects divided into 2 groups: 100 patients with diabetes type 1 and 100 patients with diabetes type 2. This study used the Mini International Neuropsychiatric Interview for the identification of psychiatric disorders.

RESULTS

Of the 200 participants, 85 (42.5%) were found to have at least 1 psychiatric disorder. The most prevalent disorders were generalized anxiety disorder (21%), dysthymia (15%), social phobia (7%), current depression (5.5%), lifelong depression (3.5%), panic disorder (2.5%), and risk of suicide (2%). Other disorders with lower prevalence were also identified. The groups showed a statistically significant difference in the presence of dysthymia, current depression, and panic disorder, which were more prevalent in patients with diabetes type 1.

CONCLUSION

The high prevalence of psychiatric disorders in diabetic patients points to the need for greater investment in appropriate diagnostic evaluation of patients that considers mental issues. The difference identified between the groups shows that preventive measures and therapeutic projects should consider the specific demands of each type of diabetes.

Health status, resource consumption, and costs of dysthymic patients in Italian primary care

Aims – To describe the health status, resource consumption and costs of patients with dysthymic disorder in the Italian primary care setting. Methods – A total of 79 general practitioners (GPs) participated the study. Diagnosis was based on each GP's clinical assessment. At entry the Mini-International Neuropsychiatric Interview (MINI) was used as a supporting diag- nostic aid. Health status was measured with the SF-36 questionnaire. Resource consumption and costs regarded the six months before enrolment. Results – Out of 598 patients enrolled by GPs according to their clinical assessment, 503 fulfilled the MINI cri- teria and 95 did not. The latter had a better perception of their health than the former. Resource consumption was similar in the two groups; and the total per patient six-month costs did not differ significantly. Conclusions – The study confirms there may be a gap between standardised criteria for defining dysthymia and everyday clinical practice. All dysthymic patients diagnosed by GPs might be considered together from a health policy perspective.

Declaration of Interest: this research was partly supported by a contribution from Sanofi-Synthelabo Italy.

The epidemiology of chronic major depressive disorder and dysthymic disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To examine the prevalence of chronic major depressive disorder (CMDD) and dysthymic disorder, their sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization.

METHOD

Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).

RESULTS

The 12-month and lifetime prevalences were greater for CMDD (1.5% and 3.1%, respectively) than for dysthymic disorder (0.5% and 0.9%, respectively). Individuals with CMDD and dysthymic disorder shared most sociodemographic correlates and lifetime risk factors for major depressive disorder. Individuals with CMDD and dysthymic disorder had almost identically high rates of Axis I and Axis II comorbid disorders. However, individuals with CMDD received higher rates of all treatment modalities than individuals with dysthymic disorder.

CONCLUSIONS

Individuals with CMDD and dysthymic disorder share many sociodemographic correlates, comorbidity patterns, risk factors, and course. Individuals with chronic depressive disorders, especially those with dysthymic disorder, continue to face substantial unmet treatment needs.

Therapeutic armamentarium for treating depression

Depressive disorders are highly prevalent and are a leading cause of disability, morbidity, and mortality worldwide; however, they often remain undertreated or untreated. This article provides a broad overview of the many strategies for treating depression. More than 24 antidepressant medications and depression-focused psychotherapies are available as first-choice options for treating depression. When patients have not had a satisfactory treatment response, the 2 main strategies are switching to an alternative antidepressant therapy or adding a second antidepressant therapy. A large number of medication combinations have been reported in the literature, and some have been shown to be effective in controlled studies. Nonstandard alternatives to conventional antidepressant treatments include exercise, light therapy, sleep deprivation, and various complementary and alternative therapies. For more chronic and refractory forms of depression, various neuromodulation therapies are available or are being investigated. Because depressive disorders are common in primary care and other medical settings, medical practitioners should be aware of the therapeutic armamentarium available for treating depression.

Critical appraisal and update on the clinical utility of agomelatine, a melatonergic agonist, for the treatment of major depressive disease in adults

This article describes the pharmacology of the novel atypical antidepressant drug agomelatine, critically reviews and evaluates its clinical use for the treatment of major depression, and suggests areas for further research. Agomelatine is a synthetic analog of the hormone melatonin. It stimulates the activity of melatonin MT1 and MT2 receptors and inhibits the activity of serotonin 5HT-2C receptor subtypes. Three acute trials demonstrated clinically modest, but statistically significant benefits over placebo. Three acute trials did not find agomelatine more effective than placebo. A meta-analysis of these six trials demonstrated a small, statistically significant, marginally clinically relevant difference between agomelatine and placebo. The only placebo-controlled study in elderly patients did not demonstrate a significant benefit for agomelatine. It was more effective than placebo in only one of two relapse prevention studies. Agomelatine was generally well tolerated compared to placebo. Its side-effect profile is different than and compares favorably to other antidepressant drugs. The overall tolerability of agomelatine in head-to-head comparisons was not substantially better than active drug comparators. Agomelatine is contraindicated in patients with impaired liver function and in patients taking drugs that potently inhibit CYP-1A2 metabolic enzymes. Because elevated liver enzymes are common, and there is a rare risk of more serious liver reactions, routine laboratory monitoring of liver function is recommended periodically throughout treatment. Agomelatine does not have clinically significant advantages compared to other antidepressant drugs, and it has certain limitations and disadvantages. Because of its unique pharmacology and relatively benign tolerability profile, however, it may be a useful alternative for patients who do not respond to or cannot tolerate other antidepressant drugs.

The three-year naturalistic course of major depressive disorder, dysthymic disorder and double depression

BACKGROUND

Recent studies support a distinction between acute and chronic forms of depression, which contrasts the single-disease hypothesis for depressive disorders. Insight into the (determinants of) the 3-year naturalistic course of major depressive disorder (MDD), dysthymic disorder (Dysth) and double depression (DD) may contribute to this debate.

METHODS

Data were derived from NEMESIS, an epidemiologic survey in the adult population of the Netherlands. 400 Respondents who met the Composite International Diagnostic Interview (CIDI) criteria of MDD and/or Dysth were selected. Cox proportional hazards analyses and Linear Mixed Models were conducted to examine 3-year course trajectories of MDD, Dysth and DD and determinants for course.

RESULTS

Adjusted analyses showed similar course trajectories for Dysth and DD, which were significantly worse than the course for MDD. Determinants of unfavorable course were neuroticism and poor functioning.

LIMITATIONS

Attrition was higher among persons with Dysth. However, since attrition is generally associated with poorer outcome, this would indicate that differences in course may even have been larger in reality.

CONCLUSIONS

Dysth and DD involve a similar course which is worse than the course of MDD only. These results do not support a distinction between Dysth and DD. Duration of symptoms and level of functioning may serve as two clinically relevant classifying dimensions within the broad category of depressive disorders.

Relationship of DSM-IV-based depressive disorders to smoking cessation and smoking reduction in pregnant smokers

This study investigated DSM-IV depressive disorders as predictors of smoking cessation and reduction in 81 pregnant smokers participating in a smoking cessation trial. Thirty-two percent of the sample met criteria for current dysthymia, major depressive disorder in partial remission, or minor depression. There was no significant reduction in smoking among women with or without current depressive disorders. Unexpectedly, as compared to women without depressive disorders, women with dysthymia significantly increased the mean number of cigarettes smoked (from 8 to 23 cigarettes per day during the 2 to 30 days post-targeted quit date period) and were smoking significantly more cigarettes at 30 days. A main effect approaching significance suggested that women with current depressive disorders were less likely to be abstinent than women without current depressive disorders (OR = 6.3; 3.9% vs. 12.7% at 30 days post-targeted quit date; 0% vs. 6.2% at 30 days post-partum). Results add to previous findings indicating a correlation between depressive symptoms and continued smoking in pregnant women. Further investigation of mood-focused smoking cessation interventions may be warranted.

Pharmacologic response to a diagnosis of late-life depression: A population study in Quebec

OBJECTIVE

To identify predictors of receiving psychoactive medication and receiving recommended first-line pharmacotherapy in individuals with newly diagnosed late-life depression.

METHODS

We undertook a retrospective database cohort study of 5258 beneficiaries of the Quebec provincial health insurance plan between 1999 and 2002. Subjects were aged 65 to 84 years and diagnosed with depression by primary care physicians or psychiatrists between October 2000 and March 2001; they had no depression diagnosis in the previous year. We defined receipt of psychoactive medication as having a pharmacy claim in the year following the depression diagnosis. We determined receipt of recommended first-line pharmacotherapy from the first psychoactive medication dispensed following diagnosis and defined it accordingly; we defined first-line pharmacotherapy according to the 2001 Canadian Psychiatric Association guidelines. We used multivariate generalized estimating equations models to identify the determinants of the 2 outcomes.

RESULTS

A total of 4421 (84.1%) patients received psychoactive medication following diagnosis; 2623 (59.3%) patients had not received antidepressants in the previous year. Of these, 1310 (49.9%) received recommended first-line pharmacotherapy. Independent predictors of receiving psychoactive medication were female sex, depression not otherwise specified (NOS), increasing comorbidity, and living in rural areas. Independent predictors of receiving recommended first-line pharmacotherapy were male sex, depression NOS, receiving medication in the month following diagnosis, and having the same physician diagnosing and treating the patient.

CONCLUSION

Male sex and continuity of care predicted that patients had the recommended medication dispensed.

Health status, resource consumption, and costs of dysthymia. A multi-center two-year longitudinal study

BACKGROUND

In this study we estimated the health status, resource consumption and costs of a large cohort of patients with early and late-onset dysthymia.

METHODS

The DYSCO (DYSthymia COsts) project is a multi-center observational study which prospectively followed for two years a randomly chosen sample of patients with dysthymia in the Italian primary health care system.

RESULTS

A total of 501 patients were followed for two years; 81% had early-onset dysthymic disorder. During the study, improvement was seen in most domains of the 36-Item Short Form Health Survey (SF-36) questionnaire. Comparison of the SF-36 scores for the two groups showed that only the physical health index significantly differed during the two years. The use of outpatient consultations, laboratory tests and diagnostic procedures was similar in the two groups, but patients with early-onset dysthymia were admitted significantly more than late-onset cases. Hospital admissions were almost entirely responsible for the higher total cost per patient per year of early-onset dysthymia.

LIMITATIONS

A first limitation of this study is that general practitioners were selected on the basis of their willingness to participate, not at random; secondly, no information was collected on concomitant psychiatric comorbidities.

CONCLUSIONS

The present study provides the first prospective, long-term data on service use and costs in patients with dysthymia. Differently from patients with early-onset dysthymia, patients with late-onset dysthymia were admitted less and cost less.

Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry

BACKGROUND

When planning and delivering a liaison psychiatry service it is important to have an understanding of the research evidence supporting the use of interventions likely to be delivered by the service.

AIMS

To identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed. The three areas were the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour.

METHOD

Computerised database searching, secondary reference searching, hand-searching and expert consultation were used to identify relevant systematic reviews. Studies were reliably selected, and quality-assessed, and data were extracted and interpreted by two reviewers.

RESULTS

We found 64 high-quality systematic reviews. Only 14 reviews included meta-analyses.

CONCLUSIONS

Many areas of liaison psychiatry practice are not based on high-quality evidence. More research in this area would help inform development and planning of liaison psychiatry services.

Depression in pregnant women seeking smoking cessation treatment

The proportion of DSM-IV-based threshold and subthreshold depressive disorders was assessed, using the Primary Care Evaluation of Mental Disorders and a DSM-IV based assessment of depression history, in a sample of 139 pregnant smokers seeking smoking cessation treatment. Sixty-three percent of the sample met criteria for a current or past depressive disorder. Forty-six percent had a current threshold or subthreshold depressive disorder. Twenty percent met criteria for current major depression, with half of those having major depression with dysthymia. Twenty-one percent of the sample was chronically depressed (i.e., dysthymia or major depression with dysthymia). Women with current depression were less likely to tell their doctors that they smoked. Our results suggest that investigation of the prevalence of depression in community samples of pregnant smokers is warranted, as depression may present a major obstacle in pregnant women's efforts to quit smoking.

Depression in general practice

The aim of this study was to examine the prevalence of depression and to investigate factors related to depression in a multi-ethnic healthcare practice population. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess mental disorders in Jordbro Health District, Haninge municipality (JHC), Sweden; 470 adult patients were consecutively examined. A two-stage-screening questionnaire was applied to identify patients reporting five or more of the nine criteria for major depression listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). This procedure was combined with a patient questionnaire (PQ) dealing with questions on socio-demographic characteristics, lifestyle, health status and medicine use. Major depression is common and in this population 18.1% met the criteria for major depression. Also, minor depression was common, with 12.1% of subjects falling into this category. Only 21.2% of the patients with major depression were being treated with anti-depressant medication. Co-morbidity was more common among depressed than among non-depressed patients. Depression seems to be under-recognized in primary care practice. The recognition and treatment of depressive disorders could be improved by using DSM-IV criteria to detect depressive disorders in daily clinical practice in primary care.

Efficacy and medical cost offset of psychosocial interventions in cancer care: Making the case for economic analyses

The burden of cancer in the worldwide context continues to grow, as incidence and mortality increase each year. Regardless of where they live, a significant proportion of cancer patients at all stages of the disease trajectory will suffer social, emotional and psychological morbidity as a result of their diagnosis and treatment. Psychosocial interventions have proven efficacious in helping patients and families overcome many of the challenges that arise consequent to a cancer diagnosis. Addressing psychosocial needs is an essential aspect of any model of adequate cancer care, however it may also prove to be a cornerstone in efforts to extend the reach of cost-effective cancer treatment to meet the growing global need. In order to set the stage for discussion of economic issues, this paper first briefly reviews the literature detailing the extent of distress and the efficacy of psychosocial treatments for cancer patients. This is followed by a summary of terminology and costing concepts in the economic evaluation of psychosocial treatments, and a review of the literature on medical cost offset in mental health, other medical populations, and in cancer patients. The literature clearly supports the notion that psychosocial interventions are not only effective, but also economical. Conclusions support adding costing data into evaluations of the efficacy of psychosocial treatments in order to detail the often present but usually overlooked long-term cost savings that may be accrued to overburdened health-care systems.

Burden of dysthymia and comorbid illness in adults in a Canadian primary care setting: high rates of psychiatric illness in the offspring

BACKGROUND

The burden of comorbid dysthymia and other comorbid psychiatric illnesses in a Canadian primary care setting was measured. Two groups of primary care patients: those who scored positive for comorbid dysthymia versus those who scored negative for any psychiatric disorder were compared.

METHODS

This was a cross-sectional survey in a Health Service Organization (HSO) in Ontario, Canada. The subjects were patients of the HSO. The main outcome measures were: health status, mood, social adjustment, coping ability, children's psychiatric disorders, child development, family function, and health and social service utilization.

RESULTS

Of the 6280 eligible adults who were patients at the HSO, 68.9% consented to be screened for psychiatric disorders; 5.1% screened positive for dysthymia, of which 90% had at least one comorbid psychiatric disorder. The following statistically significant differences were found between people with dysthymia and other comorbid psychiatric disorders versus people without any psychiatric disorder. People with dysthymia were more likely to have worse health status, worry more about their health, and report levels of pain that impaired their function; they had higher MADRS depression scores, lower social role function scores, lower social adjustment scores, and lower coping ability. More children of people with comorbid dysthymia met criteria for one or more childhood psychiatric disorders and there were more families with a parent with dysthymia that were dysfunctional. People with dysthymia used a greater proportion of health and social services, had higher per person annual health care costs (excluding hospital services), and had higher per person annual indirect costs (lost wages).

CONCLUSION

This analysis demonstrated the burden of illness and costs that this disorder imposes on individuals, their families, and society as a whole.

Patterns of medical resource and psychotropic medicine use among adult depressed managed behavioral health patients

Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning 2 years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.

Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study

Sequenced Treatment Alternatives to Relieve Depression (STAR*D) attempts to fill in major clinical information gaps and to evaluate the theoretical principles and clinical beliefs that currently guide pharmacotherapy of major depressive disorder. The study is conducted in representative participant groups and settings using clinical management tools that easily can be applied in daily practice. Outcomes include clinical outcomes and health care utilization and cost estimates. Research findings should be immediately applicable to, and easily implemented in, the daily primary and specialty care practices. This article provides the overall rationale for STAR*D and details the rationale for key design, measurement, and analytic features of the study.

Benefits of psychosocial oncology care: improved quality of life and medical cost offset

The burden of cancer in the worldwide context continues to grow, with an increasing number of new cases and deaths each year. A significant proportion of cancer patients at all stages of the disease trajectory will suffer social, emotional and psychological distress as a result of cancer diagnosis and treatment. Psychosocial interventions have proven efficacious for helping patients and families confront the many issues that arise during this difficult time. This paper reviews the literature detailing the extent of distress in patients, the staffing needed to treat such levels of distress, and the efficacy of psychosocial treatments for cancer patients. This is followed by a summary of the literature on medical cost offset in mental health, other medical populations, and in cancer patients, which supports the notion that psychosocial interventions are not only effective, but also economical. Conclusions support taking a whole-person approach, as advocated by a growing number of health care professionals, which would not only help to treat the emotional and social aspects of living with cancer, but also provide considerable long-term cost savings to overburdened health-care systems.

The search for determinants of chronic depression: a review of six factors

While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.

Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs

BACKGROUND

There is little information on the long-term effects and costs of a combination of Sertraline and interpersonal psychotherapy (IPT) for the treatment of dysthymia in primary care.

METHODS

In a single-blind, randomized clinical trial, 707 adults (18-74 years of age inclusive) with DSM-IV dysthymic disorder, with or without past and/or current major depression, as an acute or chronic episode, in a community-based primary care practice in Ontario, Canada, were randomized to treatment with either Sertraline alone (50-200 mg), or IPT alone (10 sessions), or Sertraline plus IPT combined. In the acute treatment phase (first 6 months) all groups received full active treatment. This was followed by an additional 18-month naturalistic follow-up phase. Subjects were assessed for effectiveness of treatment in reducing depressive symptoms using the Montgomery Asberg Depression Rating Scale (MADRS) at 6 months and twice again during the 18-month follow-up by blind independent observers. Treatment costs and subjects' use of other health and social services were also investigated.

RESULTS

At 6 months, 586 subjects completed the MADRS questionnaire. There was a significant difference (P=0.025) in mean MADRS scores: 14.3 (Group I); 14.9 (Group II); 16.8 (Group III), using analysis of covariance. Response (40% improvement) rates were 60.2% for Sertraline alone, 46.6% for IPT alone, and 57.5% for Sertraline augmented by IPT (P=0.02). At 2 years, 525 subjects were retained for follow-up. There was no statistically significant difference between Sertraline alone and Sertraline plus IPT in symptom reduction. However, both were more effective than IPT alone in reducing depressive symptoms (P=0.03). There was a statistically significant difference between groups in costs for use of health and social services. The IPT treatment groups had the lower costs for use of health and social services.

CONCLUSIONS

Sertraline or Sertraline plus IPT was more effective than IPT alone after 6 months. Over the long term (2 years), all three treatments provide reasonably effective treatment for reducing symptoms of dysthymia, but Sertraline or combining Sertraline with IPT is more effective than IPT alone. Of these two more effective treatments, subjects in the Sertraline plus IPT group had less health and social service costs by $480 per person over 2 years. These findings underscore the effects of combining pharmacotherapy and psychotherapy and the economic value of this more comprehensive treatment of dysthymia in primary care.

Geriatric depression, antidepressant treatment, and healthcare utilization in a health maintenance organization

OBJECTIVES

To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost.

SETTING

Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota.

PARTICIPANTS

Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516).

DESIGN

Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates.

MEASUREMENT

Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database.

RESULTS

Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges.

CONCLUSION

This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.

Predictors of nonresponse to treatment in primary care patients with dysthymia

Dysthymia is one of the most prevalent problems in primary care, especially in the elderly. In this study, we evaluated the demographic and clinical predictors of nonresponse to treatment in primary care patients with dysthymia. The study sample consisted of 338 primary care patients meeting DSMIII-R criteria for dysthymia from 4 diverse geographic sites in a randomized controlled 11-week trial of paroxetine, problem-solving therapy or placebo. Patients who attended at least 4 treatment sessions were used in the analysis. A score of less than 7 on the Hamilton was defined as a positive response to treatment. By Week 11, 52.2% of patients had a positive response to treatment. Patients with lower levels of education (odds ratio 0.44, 95% CI 0.23, 0.86), higher scores on the personality dimension of neuroticism (odds ratio 0.58, 95% CI 0.36, 0.92) and those with more severe medical illness (odds ratio 0.97, 95% CI 0.95, 0.99) were less likely to recover with either active or placebo treatments. Elderly women (>60 years of age; odds ratio 0.19, 95% CI 0.05, 0.66) were also less likely to respond to all treatments; however, females had a significantly higher response to placebo treatment compared to males. The factors associated with lack of response to treatment included lower-levels of education, high neuroticism, more severe medical illness and being an older female. This analysis is based on patients agreeing to participate in a randomized controlled trial, limiting representativeness of the sample, however, the demographic and clinical characteristics are common in elderly depressed primary care patients, and may signal the need for increased mental health specialty consultation.

Effect of group therapy for breast cancer on healthcare utilization

PURPOSE

The purpose of this study was to determine whether participation in a group psychosocial intervention by patients with breast cancer would result in an improvement in psychological measures and in reduced billings in general medical expenses.

DESCRIPTION OF STUDY

Eligible women who had completed treatment for stage 0, I, or II primary breast cancer were prospectively and randomly assigned to either the intervention (n=46) or control (n=43) group. Both groups received the usual psychosocial care; however, the intervention group also participated in six weekly cognitive/behavioral psychosocial meetings. All were assessed on psychiatric symptoms, mood, depression, and coping strategies at four time periods: pre-intervention, post-intervention, 1-year follow-up, and 2-year follow-up. Alberta Healthcare billing records were obtained covering the 2-year follow-up period to determine the amount billed per person over the course of the study.

RESULTS

Women in the intervention group had less depression, less overall mood disturbance, better overall quality of life, and fewer psychiatric symptoms than those in the control group, beginning immediately post-intervention and remaining so at 2 years post-intervention. Billing in the intervention group was an average of $147 less than in the control group, a 23.5% reduction.

CLINICAL IMPLICATIONS

This is the first study to show that a psychosocial intervention can reduce direct healthcare billings in a sample of patients with cancer. Importantly, these findings help to justify the routine availability of such programs in cancer treatment facilities worldwide.

Psychosocial considerations in elderly patients with heart failure

Neuropsychiatric conditions, such as Alzheimer's dementia, and complications, such as delirium, are common in elderly patients with heart failure. Persistent alcohol abuse and cigarette smoking sometimes contribute to the onset and progression of heart failure. Major depression and other depressive disorders are common in this population and have adverse effects on functional status, quality of life, and prognosis. Anxiety and social isolation are clinically significant problems in many cases. These problems often are treatable and deserve more clinical attention than they typically receive.

Depressive symptoms in the frail elderly: physical and psycho-social correlates

The elderly who suffer from chronic illness are at unusually high risk of depression and depressive symptoms. This study was conducted to describe the prevalence of depressive symptoms in a sample of chronically-ill elders and to examine the relationship between physical illness and depression, both as it is illuminated in a regression model and as it is understood by the respondents themselves. Interviews were conducted with a random sample of 100 clients in a community-based care program for low-income elderly at risk of nursing home placement. Over one-third of the sample (36%) reported significant depressive symptoms, as measured by the CES-D. Multiple regression analysis identified functional limitations, cognitive impairment and self-perception as significant correlates of depression in a model that explained 30 percent of the variance in CES-D scores.

Delineating psychopathologic clusters within dysthymia: a study of 512 out-patients without major depression

BACKGROUND

The literature indicates that emotional-cognitive symptoms are much more characteristic of dysthymia than the vegetative and psychomotor symptoms of major depression, yet this is insufficiently emphasized in the official criteria listed in the criteria of the American Psychiatric Association. Furthermore, as previous studies have examined these symptoms more in relation to prevalence than to possible symptom aggregation, in the present analyses we address both aspects.

METHODS

In two multicenter collaborative trials, 512 out-patients meeting the symptom criteria of DSM-III-R dysthymia but without major depression were recruited. In this respect they conformed to the conceptual framework of ICD-10 which tends to restrict dysthymia to a subthreshold depression without excursion into severe depressive episodes. The Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale (HAM-A) were used to assess depressive and anxiety symptoms.

RESULTS

Symptoms most frequently observed, besides depressed mood (100% by definition), were 'low energy or fatigue' (96%) and 'poor concentration or indecisiveness' (88%), followed by 'low self-esteem' (80%), 'insomnia or hypersomnia' (77%), 'poor appetite or overeating' (69%) and 'feeling of hopelessness' (42%). Interestingly, in the subjects with fewer than five symptoms, the most frequent were low energy or fatigue (93%), poor concentration or indecisiveness (79%) and low self-esteem (77%), the other symptoms being present in no more than half the sample. MADRS factor analysis identified two main factors: the first consisting of apparent and reported sadness, and the second concentration difficulties and lassitude. HAM-A factor analysis identified two factors clearly differentiating somatic and psychic symptoms.

LIMITATIONS

Because suicidal patients were excluded on the ground of human subject concerns, our sample is representative of the milder range of symptomatology within the spectrum of dysthymia. This may in part explain the low prevalence of neurovegetative symptoms.

CONCLUSION

Despite this, the present study involves the largest sample of pure dysthymia ever studied. Our results indicate that dysthymic disorder appears to primarily involve psychologic symptoms. The psychological symptoms themselves seem to cluster into sadness versus mental fatigue; as for anxiety symptoms, they appear divisible into somatic and psychic clusters, with the latter prevailing in dysthymia. Dysthymia proper, dominated by negative affectivity, might be distinguishable from a 'neurasthenic' subform dominated by low energy or 'deficit' symptoms at mental and physical levels.

Prevalence of dysthymic disorder in primary care

BACKGROUND

Dysthymic disorder is characterised as a chronic state of depressed mood which is not otherwise attributable to physical, psychological or social events. While it can occur alone, there is increasing evidence that the majority of individuals who meet criteria for dysthymic disorder also experience more severe episodic mood disorders throughout their lifetime, and there is also an aggregation of mood disorders within their family members. Patients with dysthymic disorder are most often seen in primary care. Some researchers suggest that the majority of these individuals are never diagnosed or are not diagnosed until a more severe episodic mood disorder develops. The objective of this study was to determine the 12-month prevalence of Axis I psychiatric disorders, and in particular dysthymic disorder, in a primary care Health Service Organization in Ontario, Canada.

METHODS

Eligible and consenting adults registered with a primary care Health Service Organization were screened using the modified form of the University of Michigan Composite International Diagnostic Interview.

RESULTS

Of the 6280 eligible subjects, 4327 (69%) consented to screening. Two hundred and twenty-two (5.1%) subjects screened positive for dysthymic disorder. In addition, 90% of those who screened positive for dysthymic disorder also screened positive for other Axis I disorders including major depressive disorder, panic, simple phobia, and generalized anxiety disorder.

CONCLUSIONS

There is much potential for the primary care physician to play a pivotal role in the recognition and treatment of dysthymic disorder and associated Axis I disorders. A focus on the family as a unit for care may be especially important given the reported aggregation of dysthymic disorder within families.

Nosological validity of dysthymia. Part I: historical, epidemiological and clinical data

Dysthymia is the last diagnostic label introduced after a series of precursors to describe a disorder whose nosological status has long been dubious. The results of published epidemiological, as well as clinical studies about its presentation, course and outcome partly support the validity of this construct — although their interpretation is limited by methodological difficulties: same prevalence in many locations in the world, always lower than that of major depression, somewhat specific clinical pattern, course and outcome.

General medical problems among the offspring of depressed parents: a 10-year follow-up

OBJECTIVE

To examine the association between both parental and offspring depression and the general medical problems of a sample of offspring at high and low risk for depression.

METHOD

Offspring (n = 222) from families with either depressed or nondepressed parents were followed up for a period of 10 years. Data collected included psychiatric diagnoses derived from direct semistructured interviews and history of general medical problems and hospital visits. Rates of medical problems and hospitalizations were calculated, and offspring were stratified by depression status of both parent and offspring.

RESULTS

In analyses controlled for sociodemographic factors, offspring depression status was associated with a history of genitourinary disorders, headaches, respiratory disorders, other disorders, and hospitalizations in the offspring, and parental depression was associated with a history of unconsciousness and hospitalization in the offspring. After subjects were stratified by parental depression, significant associations between offspring depression and medical problems were found for only those offspring with a depressed parent.

CONCLUSIONS

These findings suggest that a history of parental depression increases the risk for medical problems and hospitalization among depressed offspring. The co-occurrence of general medical and psychological problems among offspring of depressed parents may have implications for the treatment of both depression and comorbid medical disorders.

Induction of mania with serotonin reuptake inhibitors

Serotonin reuptake inhibitors (SRIs) are now considered the first-line treatment for depression, but they have not been well studied in bipolar disorder. Recently, some authors have recommended that patients at risk for antidepressant-induced mania be treated with SRIs rather than tricyclic antidepressants (TCAs). Clinical information about 11 patients who developed mania during treatment with SRIs is described. These patients were found to have personal or family histories of hypomania or mania, but these disorders were not usually recognized at the time of the patients' initial treatment for depression. The SRI-induced manic episodes were also quite severe, having psychotic features or requiring patients to be secluded for extreme agitation, but patients responded completely to antimanic treatment. The risk of treatment-emergent mania with SRIs is not trivial, especially among patients at risk for bipolar disorder. Additional research is needed to compare the actual rate of drug-induced mania with SRIs and TCAs in patients with different bipolar subtypes, while controlling for concurrent antimanic drug use.

Primary dysthymia: a study of several psychosocial, endocrine and immune correlates

The relationship between primary dysthymia (chronic, low grade depression) and indices of major and minor life stresses, uplifts and coping styles was examined. Additionally, circulating lymphocyte subsets were assessed in dysthymic patients to determine their relationship to stress/coping factors or plasma levels of cortisol, ACTH or norepinephrine. Primary dysthymia was found to be associated with increased minor stressors (daily hassles), reduced uplifts, as well as particular reliance on emotion-focused rather than problem-oriented coping strategies. Interestingly, among dysthymics, the early onset group exhibited a greater degree of hassles and greater emotion-focused coping compared to the late onset subgroup. Although hassles and coping styles were correlated with depressed mood, only coping styles predicted severity of depressed affect. It seems that although dysthymia is characterized by increased hassles and reduced uplifts, these variables do not distinguish between the severity of the depressive affect, whereas the coping styles employed in the face of the increased hassles and reduced uplifts are more closely aligned with depression severity. Dysthymia was associated with elevated levels of circulating natural killer (NK) cells. Since levels of plasma cortisol, ACTH or norepinephrine were not increased in the dysthymic subjects, it is likely that the elevated NK cell number was unrelated to these neuroendorcrine measures. In control subjects circulating NK cells were inversely related to the severity of hassles recently encountered, while in dysthymic patients stress and coping factors were unrelated to NK cell numbers. Thus, it appears that the altered NK cells in dysthymic patients were not related to the increased stress perception and altered coping which characterize these patients.

Psychiatric interventions in the medically ill. Outcome and effectiveness research

This article reviews the current status and emerging trends of outcome data from research studies of psychiatric and psychosocial interventions for mental disorders in patients in the general medical sector. Although data from such studies have had limited success to date in influencing health policy, legislators and administrators are increasingly likely to turn to outcome data to inform their decisions. The impact of psychiatric disorders, the recognition and treatment or referral of psychiatric-disordered patients by general medical practitioners, and the outcome results of psychiatric intervention programs are examined for both the inpatient and outpatient general medical sectors.

Differential diagnosis of chronic depressive disorders

This article has traced the development of the diagnostic nomenclature for the chronic affective disorders during the past four decades. Much has been accomplished. In fact, our current differential diagnostic capabilities have surpassed our knowledge of how to treat the chronic depressions. It is hoped that in the next decade there will be notable increases in the treatment efficacy literature of the chronic mild depressions. Next, we suggest that practitioners assist academic investigators in determining the best way to treat the chronic depressions. To realize this goal, clinicians must begin to view themselves as part-time researchers. Several technological procedures have been described to facilitate this undertaking. We suggest that the assumption of such a research practitioner role will, in the long run, improve the quality of patient care.

Clinical characteristics of outpatients with chronic major depression

A cross-sectional evaluation of 243 unipolar, nonpsychotic outpatients with major depression was conducted. All subjects were diagnosed by RDC with SADS-L structured interviews. Diagnoses included RDC primary/secondary, RDC endogenous/nonendogenous and Winokur's family-history subtypes. Symptom severity was assessed by the 17-item Hamilton Rating Scale for Depression. Chronic depression was defined as the current episode of major depression lasting at least 2 years, corresponding to DSM-III-R and -IV criteria. Patients with chronic depression (n = 64) were compared with those with nonchronic depression (n = 179). Chronicity was not related to gender, symptom severity, prior length of illness, age at onset of illness, RDC endogenous/nonendogenous, RDC primary/secondary or Winokur's family-history subtypes. Those with chronic depression were older and had fewer major depressive episodes than the nonchronic group. That the chronic group had fewer total episodes of depression than the nonchronic group, but a similar age at onset, is consistent with the notion that patients in a current chronic episode have characteristically longer depressive episodes throughout the course of their illness. Those with chronic episodes may be subject to psychological, biological and/or sociocultural factors that preclude an earlier episode remission for these individuals.