The MAKE Biomarker Discovery for Enhancing anTidepressant Treatment Effect and Response (MAKE BETTER) Study: Design and Methodology

Interaction Effect of Childhood Abuse History and Suicidality on 12-Month Antidepressant Response in Patients With Depressive Disorder

OBJECTIVE

We aimed to identify the individual and interactive effects of childhood abuse and suicidal ideation on antidepressant treatment response in 12 months.

METHODS

In this prospective research, 1,262 depressive patients were asked about their childhood abuse history, suicidal ideation, and other clinical characteristics and socio-demographic features at baseline, and 1,015 of them were followed during 1 year of stepwise pharmacotherapy. The individual and interactive relationships of the childhood abuse history and suicidal ideation on 12-month antidepressant non-remission were explored by logistic regression with relevant covariates.

RESULTS

Having a childhood abuse history and higher suicidal ideation significantly predicted a non-remission state in 12 months respectively. The interaction term of childhood abuse and suicidal ideation was also significantly related to a non-remission state at 12 months. To be specific, in the low suicidal ideation group, depressive patients with a childhood abuse history were more likely to be in a non-remission state after 12 months of medication. In the high suicidal ideation group, however, childhood abuse history was not significantly associated with the non-remission state at 12 months.

CONCLUSION

The childhood abuse history and the level of suicidal ideation are informative factors predicting the long-term results of antidepressant treatment, especially when they are combined. Clinicians may consider antidepressants with a higher affinity for patients with childhood abuse history even if they don't have suicidal ideation. The cognitive intervention for suicidal ideation might be helpful in addition to pharmacological treatment.

Use of Serum Biomarkers to Aid Antidepressant Selection in Depressive Patients

Objective

: This study aimed to identify serum biomarkers prospectively associated with remission at 12 weeks in out-patients with depressive disorders receiving stepwise psychopharmacotherapy, according to the main antidepressant used during the treatment period.

Methods

: This study included 1,024 depressive outpatients initially treated using antidepressant monotherapy, followed by alternating pharmacological strategies during the acute phase (3-12 weeks; 3-week interval). Fourteen serum biomarkers, sociodemographics, and clinical characteristics were evaluated at baseline. Based on the use frequency and mechanism of action, four main antidepressant types were distinguished: escitalopram, other selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and mirtazapine. A Hamilton Depression Rating Scale score ≤ 7 was take to indicate remission.

Results

: Lower high-sensitivity C-reactive protein levels were correlated with remission at 12 weeks for all antidepressant types. Lower interleukin (IL)-6 levels and tumor necrosis factor-alpha levels were associated with remission using escitalopram and other SSRIs respectively. Lower IL-1β and leptin levels, predicted remission in association with SSRIs including escitalopram. For SNRIs, remission at 12 weeks was predicted by lower IL-4 and IL-10 levels. For mirtazapine, remission at 12 weeks was associated with lower leptin levels, and higher serotonin and folate levels.

Conclusion

: Baseline serum status, as estimated by nine serum markers, may help clinicians determine the most appropriate antidepressant to achieve remission in the acute phase of depression.

Multiple serum biomarkers for predicting suicidal behaviours in depressive patients receiving pharmacotherapy

BACKGROUND

Predictive values of multiple serum biomarkers for suicidal behaviours (SBs) have rarely been tested. This study sought to evaluate and develop a panel of multiple serum biomarkers for predicting SBs in outpatients receiving a 12-month pharmacotherapy programme for depressive disorders.

METHODS

At baseline, 14 serum biomarkers and socio-demographic/clinical characteristics including previous suicidal attempt and present suicidal severity were evaluated in 1094 patients with depressive disorders without a bipolar diagnosis. Of these, 884 were followed for increased suicidal severity and fatal/non-fatal suicide attempt outcomes over a 12-month treatment period. Individual and combined effects of serum biomarkers on these two prospective SBs were estimated using logistic regression analysis after adjustment for relevant covariates.

RESULTS

Increased suicidal severity and fatal/non-fatal suicide attempt during the 12-month pharmacotherapy were present in 155 (17.5%) and 38 (4.3%) participants, respectively. Combined cortisol, total cholesterol, and folate serum biomarkers predicted fatal/non-fatal suicide attempt, and these with interleukin-1 beta and homocysteine additionally predicted increased suicidal severity, with clear gradients robust to adjustment (p values < 0.001).

CONCLUSIONS

Application of multiple serum biomarkers could considerably improve the predictability of SBs during the outpatient treatment of depressive disorders, potentially highlighting the need for more frequent monitoring and risk appraisal.

Age-specific associations between inflammatory markers and remission of depression during antidepressant use

The roles of inflammatory markers in predicting the response to antidepressants are controversial. The levels of inflammatory markers increase with age. Here, we compared the associations of inflammatory markers with remission during 12-week pharmacotherapy according to patient age. Higher high-sensitivity C-reactive protein (hsCRP) levels were associated with non-remission in younger, but not older, patients. However, higher interleukin (IL)-1β and IL-6 levels were associated with non-remission in all patients, regardless of age. Differential associations were observed between inflammatory markers and remission, according to patient age. Patient age should be considered when predicting the response to antidepressants based on serum hsCRP level.

Age-specific associations between serum cholesterol levels and suicidal behaviors in patients with depressive disorders: A naturalistic prospective observational cohort study

Introduction

This study investigated the effects of total cholesterol levels on prevalent, and incident suicidal behaviors according to age group (<60 vs. ≥60 years) in depressed patients.

Methods

Consecutive outpatients with depressive disorders who visited the Chonnam National University Hospital between March 2012 and April 2017 were recruited. Among 1,262 patients assessed at baseline, 1,094 agreed to blood sampling for measurement of serum total cholesterol levels. Among the patients, 884 completed the 12-week acute treatment phase and were followed up at least once during the 12-month continuation treatment phase. Suicidal behaviors assessed at baseline included baseline suicidal severity; behaviors assessed at the 1-year follow-up included increased suicidal severity and fatal/non-fatal suicide attempts. Associations of baseline total cholesterol levels with the above-mentioned suicidal behaviors were analyzed using logistic regression models after adjustment for relevant covariates.

Results

Of 1,094 depressed patients, 753 (68.8%) were women. The mean (SD) age of patients was 57.0 (14.9) years. Lower total cholesterol levels (87-161 mg/dl) were associated with increased suicidal severity (Linear Wald = 4.478, p < 0.05) and fatal/non-fatal suicide attempt (Linear Wald = 7.490, p < 0.01) in patients <60 years of age. U-shaped associations between total cholesterol levels and 1-year follow-up suicidal outcomes (increased suicidal severity, Quadratic Wald = 6.299, p < 0.05; fatal/non-fatal suicide attempt, Quadratic Wald = 5.697, p < 0.05) were observed in patients ≥60 years of age.

Conclusions

These findings suggest that differential consideration of serum total cholesterol levels according to age group may have clinical utility for predicting suicidality in patients with depressive disorders. However, because our research participants came from a single-hospital, the generalizability of our findings may be limited.

Interaction effect between childhood abuse and interleukin-1β levels on suicidality in depressed patients

INTRODUCTION

The roles of childhood abuse and interleukin (IL)-1β levels, a representative pro-inflammatory cytokine, in suicidal behavior are unclear. This study investigated the main and interactive effects of childhood abuse and IL-1β levels on suicidal behavior in patients with a depressive disorder before and after pharmacological treatment.

METHODS

At baseline, exposure to self-reported childhood abuse, including emotional, physical, and sexual abuse, before the age of 16 years, and IL-1β levels, were measured in 1,094 outpatients with a depressive disorder, 884 of whom were followed for 1 year. Suicidal behavior was evaluated, including previous suicide attempts (at baseline), suicidal ideation (at baseline and follow-up), and fatal/non-fatal suicide attempts (at follow-up). The main and interaction effects of self-reported childhood abuse and IL-1β level on the four types of suicidal behavior were analyzed using logistic regression after adjusting for covariates.

RESULTS

Individual associations of self-reported childhood abuse were significant only with previous suicidal attempt but not with other suicidal behaviors. There was no significant association of plasma IL-1β level with any suicidal behavior. There were significant interactive associations of self-reported childhood abuse and a high IL-1β level on previous suicide attempts, baseline suicidal ideation, and fatal/non-fatal suicidal attempts during follow-up.

CONCLUSION

Suicidal behavior in patients with a depressive disorder could be influenced by considering the interactive effect of childhood abuse and IL-1β levels. Our study suggests that childhood trauma and biochemical factors play roles in the pathology of suicide in depressed patients.

Interactive Effects of Serum Leptin Levels and Physical Comorbidity on the Pharmacotherapeutic Response of Depressive Disorders

OBJECTIVE

To investigate individual and interactive associations of baseline serum leptin levels and physical comorbidity with short- and long-term treatment outcomes in outpatients with depressive disorders who received stepwise antidepressant treatment in a naturalistic prospective study design.

METHODS

Baseline serum leptin levels were measured, and the number of concurrent physical disorders ascertained from 1,094 patients. These patients received initial antidepressant monotherapy; then, for patients with an insufficient response or who experienced uncomfortable side effects, treatment was administered using alternative strategies every 3 weeks in the acute treatment phase (at 3, 6, 9, and 12 weeks) and every 3 months in the continuation treatment phase (at 6, 9, and 12 months). Then, 12-week and 12-month remission, defined as a Hamilton Depression Rating Scale score of ≤7, was estimated.

RESULTS

In multivariable logistic regression analyses, individual effects were found only between higher baseline serum leptin levels and 12-week non-remission. Significant interactive effects between higher leptin levels and fewer physical disorders (< 2 physical disorders) on 12-week non-remission were observed. However, neither individual nor interactive effects between leptin levels and physical comorbidity were associated with 12-month remission.

CONCLUSION

The combination of serum leptin level and number of physical disorders may be a useful predictor of short-term treatment responses in patients with depressive disorders receiving pharmacotherapy.

Prediction of 12-Week Remission by Psychopharmacological Treatment Step in Patients With Depressive Disorders

OBJECTIVE

To investigate the predictors of remission by 4 treatment steps in depressive outpatients receiving 12-week psychopharmacotherapy.

METHODS

Patients were consecutively recruited at a university hospital in South Korea from March 2012 to April 2017. At baseline, 1,262 patients were evaluated for sociodemographic and clinical data including assessments scales, and were received antidepressant monotherapy. For patients with an insufficient response or uncomfortable side effects, next treatment steps (1, 2, 3, and 4) with alternative strategies (switching, augmentation, combination, and mixtures of these approaches) were administered considering measurements and patient preference at every 3 weeks in the acute treatment phase (3, 6, 9, and 12 weeks). Remission was defined as a Hamilton Depression Rating Scale score of ≤7.

RESULTS

In the multi-variate logistic regression analyses, remission was predicted by higher functional levels in patients received Step 1 and 2 treatment; by lower life stressors in Step 1; by higher social support in Step 3 and 4; and by lower suicidality in Step 1-3.

CONCLUSION

Differential associations were found between symptoms or functions and treatment steps, which suggested that multi-faceted evaluations at baseline could predict remission by treatment steps.

Prospective associations of multimodal serum biomarkers with 12-week and 12-month remission in patients with depressive disorders receiving stepwise psychopharmacotherapy

Prognostic biomarkers for depression treatment outcomes have yet to be elucidated. This study sought to evaluate whether a multi-modal serum biomarker panel was prospectively associated with 12-week and 12-month remission in outpatients with depressive disorders receiving stepwise psychopharmacotherapy. At baseline, 14 serum biomarkers and socio-demographic/clinical characteristics were evaluated in 1094 patients. They received initial antidepressant monotherapy followed, as required by a protocol of successive alternative pharmacological strategies administered in 3-week steps during the acute (3-12 week) phase (N = 1086), and in 3-month steps during the continuation (6-12 month) phase (N = 884). Remission was defined as a Hamilton Depression Rating Scale score of ≤ 7. Remission was achieved in 490 (45.1%) over the 12-week, and in 625 (70.7%) over the 12-month, treatment periods. Combination scores of four serum biomarkers (high-sensitivity C-reactive protein, interleukin-1 beta, interleukin-6, and leptin) were prospectively associated with 12-week remission; and four (high-sensitivity C-reactive protein, tumor necrosis factor-alpha, interleukin-1 beta, and brain-derived neurotrophic factor) were prospectively associated with 12-month remission in a clear gradient manner (P-values < 0.001) and after adjustment for relevant covariates. These associations were evident after the Step 1 treatment monotherapy but weakened with increasing treatment steps, falling below statistical significance after 4 + treatment steps. Application of combined multiple serum biomarkers, particularly on inflammatory markers, could improve predictability of remission at acute and continuation treatment phases for depressive disorders. Patients with unfavourable biomarkers might require alternative treatment regimes for better outcomes.

Interaction effect of the serum interleukin-6 level and anxiety on the 12-week pharmacotherapeutic responses of patients with depressive disorders

BACKGROUND

Despite the pathogenic role played by interleukin-6 (IL-6) signaling in depression, the association between baseline peripheral IL-6 signaling and the antidepressant treatment responses noted in clinical studies remains controversial. We investigated the effects of the baseline serum IL-6 (sIL-6) level and anxiety symptoms on the 12-week remission rate of depressed outpatients who received stepwise antidepressant treatments.

METHODS

At baseline, sIL-6 levels were measured, and anxiety symptoms were evaluated using the Hospital Anxiety Depression Scale-Anxiety subscale (HADS-A), in 1094 patients. All received stepwise antidepressant treatment. Subsequently, 12-week remission, defined as a Hamilton Depression Rating Scale (HAMD) score ≤ 7, was assessed.

RESULTS

The individual and interaction effects of the sIL-6 level (as a binary [low vs. high, based on the median value of 1.65 pg/mL] or continuous variable) and the HADS-A score (as a binary [<12 vs. ≥12] or continuous variable) on the 12-week remission rate were analyzed using logistic regression models after adjusting for relevant covariates. Patients with both low sIL-6 levels (<1.65 pg/mL) and HADS-A scores <12 had the highest 12-week remission rate; a significant interaction effect was also apparent. This effect was significant even when the data were analyzed as continuous variables.

CONCLUSIONS

Our study suggests that the sIL-6 level can serve as a biomarker predicting the outcome of antidepressant treatment according to the severity of anxiety symptoms.

Associations of serum cortisol levels, stress perception, and stressful events with suicidal behaviors in patients with depressive disorders

BACKGROUND

Stress is a well-known risk factor of suicide. However, there is a lack of research on the best psychobiological markers of stress for monitoring and predicting suicidal behaviors in depressed patients. We aimed to investigate the individual and interactive effects of serum cortisol levels and stress-related parameters, including perceived stress and life stressors, on suicidal behavior in depressed patients.

METHODS

At baseline, serum cortisol levels were measured and stress-related data, i.e., Perceived Stress Scale (PSS) scores and the number of stressful life events (SLEs), were collected from 1,094 patients with a depressive disorder, of whom 884 were followed up for 1 year. Suicidal behaviors evaluated at baseline included previous suicide attempts and baseline suicidal severity, while those at the 1-year follow-up were increased suicidal severity and fatal/non-fatal suicide attempts. Individual and interactive associations of exposure variables with suicidal outcomes were analyzed using logistic regression models after adjusting for relevant covariates.

RESULTS

Higher serum cortisol levels were significantly associated with suicidal outcomes at the 1-year follow-up. In addition, higher PSS scores were significantly associated with higher baseline severity, whereas the number of SLEs was not associated with any suicidal outcomes. A significant interactive effect of cortisol level and PSS score on suicidal outcomes at the 1-year follow-up was observed. Higher cortisol levels and PSS scores were associated with increased suicidal severity and more fatal/non-fatal suicide attempts.

CONCLUSIONS

The combination of serum cortisol levels and PSS scores may be useful for monitoring and predicting suicidal behaviors in depressed patients.

Childhood Abuse, Social Support, and Long-Term Pharmacological Treatment Outcomes in Patients With Depressive Disorders

OBJECTIVES

This study was performed to investigate the roles of childhood abuse and social support in predicting short- and long-term pharmacological treatment outcomes in outpatients with depressive disorders in a naturalistic 1-year prospective design.

METHODS

Patients were recruited at a university hospital in South Korea between March 2012 and April 2017. Subjects with stepwise pharmacotherapy (switching, augmentation, combination, and mixture of these approaches) included 1246 patients at 12-week points in the acute treatment response and 1,015 patients at 12-months in the long-term treatment response. Remission was defined as Hamilton Depression Rating Scale score ≤ 7. Exposure to three types of childhood abuse (physical, emotional, and sexual) before the age of 16 and perceived social support were assessed at baseline.

RESULTS

Individual associations of childhood abuse were associated with poorer treatment outcomes in the 12-month long-term phase, and no significant individual associations were found for social support level with any period outcome. In combination, any child abuse, emotional abuse, and physical abuse were significantly associated with long-term 12-month remission rate in the presence of higher level of social support after adjustment with significant interaction terms. However, no significant interactions were found with sexual abuse.

CONCLUSION

Synergistic interactive effects of child abuse and social support levels on treatment outcomes in depressive patients were found during long-term pharmacotherapy. Thus, depressed patients with a history of childhood abuse may require specialized clinical approaches, including social support, to enhance the long-term treatment outcomes.

Interaction effect of serum serotonin level and age on the 12-week pharmacotherapeutic response in patients with depressive disorders

Despite the recognized antidepressant role of serotonin (5-hydroxytryptamine [5-HT]) signaling pathways in the central nervous system, the association between baseline peripheral 5-HT level and the antidepressant treatment response in clinical studies remains debatable. We investigated the interaction effects of baseline serum 5-HT level and age on the 12-week remission in outpatients with depressive disorders who received stepwise antidepressant treatment. Baseline serum serotonin levels were measured and the age of 1094 patients recorded. The patients received initial antidepressant monotherapy; then, patients with an insufficient response or who experienced uncomfortable side effects received alternative treatments every 3 weeks (3, 6, and 9 weeks). Subsequently, 12-week remission, defined as a Hamilton Depression Rating Scale (HAMD) score of ≤ 7, was evaluated. Individual and interaction effects of serum 5-HT level (as a binary [low vs. high, based on the median value of 72.6 ng/mL] or continuous variable) and age (as a binary [< 60 vs. ≥ 60 years] or continuous variable) on the 12-week remission rate were analyzed using logistic regression models after adjusting for relevant covariates. High 5-HT (≥ 72.6 ng/mL) and age ≥ 60 years were associated with the highest 12-week remission rates and a significant multiplicative interaction effect. The interaction effect of the two variables on the 12-week remission rate was significant even when analyzed as a continuous variable. Our study suggests that the association between baseline serum 5-HT level and 12-week antidepressant treatment outcomes differs according to patient age.

Synergistic effects of resilience and serum ghrelin levels on the 12-week pharmacotherapeutic response in patients with depressive disorders

BACKGROUND

This study investigated the individual and combined effects of self-reported resilience and serum ghrelin levels on 12-week remission in outpatients with depressive disorders who received antidepressant treatment.

METHODS

The Connor-Davidson Resilience Scale (CDRS) score and serum ghrelin levels were assessed at baseline in 1,094 patients. The patients initially received antidepressant monotherapy. Patients with an insufficient response or uncomfortable side effects received alternative treatments every 3 weeks (at 3, 6, and 9 weeks). Subsequently, 12-week remission, defined as a Hamilton Depression Rating Scale (HAMD) score of ≤ 7, was evaluated. The individual and combined effects of the CDRS score (low vs. high) and serum ghrelin level (low vs. high) on 12-week remission were analyzed using logistic regression models after adjusting for relevant covariates.

RESULTS

The individual effects of the CDRS score and serum ghrelin level on 12-week remission were not statistically significant. However, the high-CDRS, high-ghrelin group had a significantly higher 12-week remission rate compared to the low-CDRS, low-ghrelin group.

CONCLUSIONS

The combination of the CDRS score and serum ghrelin level is useful for predicting 12-week remission in patients with depressive disorders receiving pharmacotherapy.

Investigating associations of childhood abuse and serum brain-derived neurotrophic factor levels with suicidal behaviours in patients with depressive disorders

BACKGROUND

The role of childhood abuse and serum brain-derived neurotrophic factor (BDNF) levels in suicidal behaviour is controversial.

AIMS

We aimed to investigate the individual and interactive effects of the childhood abuse and serum BDNF on suicidal behaviour before and after pharmacologic treatment in patients with depressive disorders.

METHOD

At baseline, reported childhood emotional, physical and sexual abuse were ascertained and serum BDNF levels were measured in 1094 patients with depressive disorder, 884 of whom were followed during a 1-year period of stepwise pharmacotherapy. Suicidal behaviours evaluated at baseline were previous suicide attempt and baseline suicide severity, and suicidal behaviours evaluated at follow-up were increased suicide severity and fatal/non-fatal suicide attempt. Individual and interactive associations of any childhood abuse and serum BDNF levels with four types of suicidal behaviours were analysed using logistic regression models, after adjusting relevant covariates.

RESULTS

Individual associations of childhood abuse were significant only with previous suicide attempt, and no significant individual associations were found for serum BDNF with any suicide outcome. However, the presence of both childhood abuse and lower serum BDNF levels was associated with the highest prevalence/incidence of all four suicidal behaviours, with significant interactions for baseline suicide severity and fatal/non-fatal suicide attempt during follow-up.

CONCLUSIONS

Synergistic interactive effects of child abuse and serum BDNF levels on suicidal behaviours were found before and after pharmacologic treatment in patients with depressive disorders. Information combining childhood abuse and serum BDNF levels could improve predictions of suicidal behaviour in patients with depressive disorders.

Predictors and outcomes of experienced and anticipated discrimination in patients treated for depression: A 2-year longitudinal study

BACKGROUND

Stigma is both common and associated with greater depressive morbidity in depressives. Surprisingly few longitudinal studies have explored the predictors and consequences of stigma and discrimination.

METHOD

A total of 230 patients with depression who were commencing treatment were enrolled. Experienced and anticipated discrimination were assessed using the Discrimination and Stigma Scale at the 1-year follow-up. The Hamilton Rating Scale for Depression, Hospital Anxiety and Depression Scale, Clinical Global Impression Scale-Severity, Social and Occupational Functioning Assessment Scale (SOFAS), EuroQol-5 Dimension (EQ-5D) questionnaire, and Sheehan Disability Scale were administered at baseline, 1 year, and 2 years, to assess various depression outcomes. Baseline personality was evaluated using the Big Five Inventory-10.

RESULTS

A previous depressive history and low agreeableness predicted experienced discrimination; a higher level of education, non-married status, and higher functional disability predicted anticipated discrimination. Higher-level experienced discrimination during the first year of treatment was significantly associated with poorer improvements in all six measured outcomes after 1 year of treatment, and again after 2 years of treatment (with the exception of the EQ-5D score). Higher anticipated discrimination was significantly associated with less improvement in the SOFAS scores after both 1 and 2 years of treatments.

LIMITATIONS

The study was a single-center work; this maximized consistency but may limit generalizability.

CONCLUSIONS

Discrimination exerts negative effects on depression outcomes that can be predicted at the initiation of treatment. Interventional studies are required to prevent and manage stigmatization of persons with depression.

Predictors of relapse following a stepwise psychopharmacotherapy regime in patients with depressive disorders

BACKGROUND

Real world predictors of relapse following routine treatment for depression remain under-researched. We sought to investigate this in an outpatient clinical sample with depressive disorders receiving stepwise pharmacotherapy based on early clinical decision-making, applying a naturalistic 24-month prospective design.

METHODS

Patients were recruited at a University hospital in South Korea from March 2012 to April 2017. After 3-week antidepressant monotherapy (N = 1262), next treatment steps (1, 2, 3, and 4 or over) with alternative strategies (switching, augmentation, combination, and mixtures of these approaches) were administered based on measurements and patient preference at 3-week points in the acute treatment phase (3, 6, 9, and 12 weeks) (N = 1246). For those who responded [Hamilton Depression Rating Scale (HAMD) score of≤14] (N = 937), relapse (HAMD>14) was identified every 3 months from 6 to 24 months (N = 816). Predictors of relapse were evaluated using multi-variate Cox proportional hazards models.

RESULTS

Four independent relapse predictors were identified: higher number of previous depressive episodes, higher anxiety at baseline, higher number of treatment steps, and poor medication adherence. In particular, treatment Step 4 was significantly associated with relapse compared to treatment Step 1, 2, and 3 after adjustment for relevant covariates.

LIMITATION

Withdrawal syndromes after discontinuing psychotropic drugs, known to confound the determination of relapse, were not evaluated. The study was conducted at a single site, which maximised consistency but may limit generalizability.

CONCLUSIONS

Predictors of relapse reported from more restricted trial or cohort samples were replicated in this long-term naturalistic prospective design.

Predictive values of tumor necrosis factor-α for depression treatment outcomes: effect modification by hazardous alcohol consumption

Inflammation is potentially associated with poor antidepressant treatment outcomes. Pro-inflammatory cytokines are influenced by hazardous alcohol consumption. The aim of the present study was to investigate the effects of the serum tumor necrosis factor-α (sTNF-α) level on antidepressant treatment outcomes in terms of the 12-week and 12-month remission rates and 24-month relapse rate, and to investigate the potential modifying effects of alcohol consumption on these associations in patients with depressive disorders. At baseline, sTNF-α was measured and alcohol-related data from the Alcohol Use Disorders Identification Test (AUDIT) and consumption history were collected from 1094 patients. Patients received stepwise antidepressant treatment. Remission at 12 weeks and 12 months was defined as a Hamilton Depression Rating Scale (HAMD) score ≤ 7. Relapse (HAMD score ≥ 14) was identified until 24 months for those who had initially responded (HAMD score <14) at 12 weeks. Higher sTNF-α levels were found to have significant effects on the 12-week and 12-month non-remission and 24-month relapse rates. These effects were more prominent in those with low levels of alcohol consumption (AUDIT score ≤ 8 or no current alcohol consumption); the effects were not significant in those exhibiting hazardous alcohol consumption (AUDIT score > 8 or current drinking). Significant interactions were found for the 12-month non-remission and relapse rates, although the interaction was not statistically significant for 12-week remission. In conclusion, baseline sTNF-α levels may be a useful predictor for both short- and long-term antidepressant treatment outcomes, and the consideration of alcohol consumption status may increase predictability, in particular for long-term outcomes.

Predictors of Remission in Acute and Continuation Treatment of Depressive Disorders

Objective

To identify factors predicting remission of depression during acute (12 weeks) and continuation treatment (12 months) using a 1-year, naturalistic prospective study design.

Methods

Patients with depressive disorders were recruited from Chonnam National University Hospital in South Korea from March 2012 to April 2017. At baseline, 1,262 patients received outpatient therapy, and sociodemographic and clinical data were obtained. Clinical visits took place every 3 weeks during the acute treatment phase (at 3, 6, 9, and 12 weeks; n = 1,246), and every 3 months during the continuation treatment phase (at 6, 9, and 12 months; n = 1,015). Remission was defined as a Hamilton Depression Rating Scale score ≤ 7.

Results

The remission rate was 43.3% at 12 weeks and 70.4% at 12 months. In multivariate analyses, remission during the acute treatment phase was more likely in patients with a shorter-duration present episode, higher functioning, and good social support. Remission during the continuation treatment phase was more likely in patients with fewer previous depressive episodes and/or a lower baseline stress score.

Conclusion

Factors predicting depressive disorder remission may differ between the acute and continuation treatment phases.

Interactive effects of systemic inflammation and life stressors on treatment response of depressive disorders

Inflammation is an important contributor in the pathophysiology of depression and recent evidence suggests that systemic inflammation and life stressors have interactive roles in depression onset. The aim of the present study was to investigate the individual and interactive effects of systemic inflammation and life stressors with short- and long-term treatment responses in outpatients with depressive disorders in a naturalistic one-year prospective design. Serum high-sensitivity C-reactive protein (hsCRP) levels were measured and number of stressful life events (SLEs) during the last 3 months were ascertained from 1094 patients at baseline. These patients received initial antidepressant monotherapy, then, for patients with an insufficient response or uncomfortable side effects, next treatment with alternative strategies were administered at every 3 weeks in the acute treatment phase (3, 6, 9, and 12 weeks) and at every 3 months in the continuation treatment phase (6, 9, and 12 months). 12-week and 12-month remission was estimated, defined as a Hamilton Depression Rating Scale score of ≤ 7. In multivariable logistic regression analyses, individual effects were found only between higher baseline serum hsCRP levels (≥1.0 vs. < 1.0 mg/L) and 12-week non-remission. Significant interactive effects between higher hsCRP levels and higher number of SLEs (≥2 vs. < 2) on both 12-week and 12-month non-remission were observed. Combining serum hsCRP levels and number of SLEs might therefore be a useful predictor for short- and long-term treatment responses in patients with depressive disorders receiving pharmacotherapy.

Genetic markers for depressive disorders with earlier age at onset

Age at onset has been considered a potential indicator of underlying genetic risk in depression research. However, the variants associated with earlier age at onset of depressive disorder have not been elucidated. To evaluate the genetic architecture of depression onset, whole-exome sequencing of samples from 1000 patients with depressive disorder was performed. Cox proportional hazard models with false discovery rate-adjusted P-values were used to estimate the hazard ratios; carriers and non-carriers of individual coding variants were compared in terms of age at onset of depression with adjustment for sociodemographic and clinical characteristics. The clinical relevance of the candidate variants was also examined. Whole-exome sequencing revealed four variants in the CCL14, FYB, GPRASP1, and CTNND2 genes associated with an increased risk of depressive disorder with earlier age at onset. Although no individual variant was associated with any clinical characteristic except AAO, together they were associated with younger AAO, younger age at visit for treatment, and recurrent and atypical depression. Our data suggest novel candidate genes for depressive disorder with earlier age at onset. These genes could serve as markers allowing early identification of patients at risk of depression, and thus earlier intervention.

Prediction of Suicidality According to Serum Folate Levels in Depressive Patients Receiving Stepwise Pharmacotherapy

Background: The effects of serum folate levels on suicidal behavior, strongly associated with depression, have not been investigated. Therefore, this study investigated the associations between serum folate levels and suicidal behavior in patients with depressive disorders. Methods: Serum folate levels were measured at baseline in 1,094 patients with depressive disorder, 884 of whom were followed during a 12-month period of stepwise pharmacotherapy. Suicidal behaviors evaluated at baseline were (i) previous suicide attempt and (ii) baseline suicidal severity; behaviors evaluated at follow-up were (iii) increased suicidal severity and iv) fatal/non-fatal suicide attempt. Associations of serum folate levels with four types of suicidal behaviors were analyzed using logistic regression models after adjustment for relevant covariates; they were also examined using area under receiver operating characteristic (AUROC) curve analyses. Results: Reduced serum folate levels (<6.0 ng/mL) were independently associated with all four types of suicidal behaviors. AUROC curve analyses indicated that discriminant or prognostic values of reduced serum folate levels were fair for fatal/non-fatal suicide attempt during follow-up, whereas they were modest for previous suicide attempt, baseline suicidal severity, and increased suicidal severity. Conclusions: Serum folate levels could serve as a biomarker of suicidal behavior in depressive patients. However, it should be used as an adjunct rather than a substitute for prediction of suicidal behavior considering its low prognostic values. Further replication studies are needed for its clinical utilization.

Short and long-term treatment outcomes of stepwise psychopharmacotherapy based on early clinical decision in patients with depressive disorders

BACKGROUND

To investigate the effects of stepwise pharmacotherapy based on early clinical decision-making on short- and long-term treatment outcomes in outpatients with depressive disorders in a naturalistic one-year prospective design.

METHODS

Patients were recruited at a University hospital in South Korea from March 2012 to April 2017. At baseline, 1262 patients received antidepressant monotherapy. For patients with an insufficient response or uncomfortable side effects, next treatment steps (1, 2, 3, and 4 or over) with alternative strategies (switching, augmentation, combination, and mixtures of these approaches) were administered considering measurements and patient preference at every 3 weeks in the acute treatment phase (3, 6, 9, and 12 weeks) (N=1246), and at every 3 months in the continuation treatment phase (6, 9, and 12 months) (N=1015). Remission was defined as a Hamilton Depression Rating Scale score of ≤ 7.

RESULTS

Remission was more frequently achieved with increasing treatment steps and advanced treatment strategies over the treatment period, while the superior effect of treatment Step 4 or over no longer persisted in the continuation treatment phase. Augmentation + combination strategy was associated with the best outcome, with least benefit associated with a switching strategy compared to monotherapy continuation. Adverse events were more frequent with increasing treatment steps and advanced treatment strategies, while numbers of visits did not statistically differ by treatment steps or strategies.

LIMITATION

The lack of a comparison group without early clinical decision due to the descriptive nature of study design limits to prove directly the study question.

CONCLUSIONS

A stepwise pharmacotherapy approach based on early clinical decision-making in the light of measurements and patient preference could enhance both short- and long-term treatment outcomes in depressive disorders.

Genetic Markers for Later Remission in Response to Early Improvement of Antidepressants

Planning subsequent treatment strategies based on early responses rather than waiting for delayed antidepressant action can be helpful. We identified genetic markers for later non-remission in patients exhibiting poor early improvement using whole-exome sequencing data of depressive patients treated in a naturalistic manner. Among 1000 patients, early improvement at 2 weeks (reduction in Hamilton Depression Rating Scale [HAM-D] score ≥ 20%) and remission at 12 weeks (HAM-D score ≤ 7) were evaluated. Gene- and variant-level analyses were conducted to compare patients who did not exhibit early improvement and did not eventually achieve remission (n = 126) with those who exhibited early improvement and achieved remission (n = 385). Genes predicting final non-remission in patients who exhibited poor early improvement (COMT, PRNP, BRPF3, SLC25A40, and CGREF1 in males; PPFIBPI, LZTS3, MEPCE, MAP1A, and PFAS in females; ST3GAL5 in the total population) were determined. Among the significant genes, variants in the PRNP (rs1800014), COMT (rs6267), BRPF3 (rs200565609), and SLC25A40 genes (rs3213633) were identified. However, interpretations should be made cautiously, as complex pharmacotherapy involves various genes and pathways. Early detection of poor early improvement and final non-remission based on genetic risk would be helpful for decision-making in a clinical setting.

Standardization of the Discrimination and Stigma Scale-Korean Version (DISC 12-K) in Patients with Depressive Disorders

OBJECTIVE

The Discrimination and Stigma Scale (DISC 12), which assesses behavioral and experienced stigma, has not been translated into Korean. We developed and standardized the Korean version of the DISC 12 (DISC 12-K) in patients with depressive disorders.

METHODS

The study included 230 patients with depressive disorders who were assessed on the four subscales of the DISC 12-K: Unfair Treatment, Stopping Self, Overcoming Stigma, and Positive Treatment. Additionally, stigma was assessed using the Internalized Stigma of Mental Illness scale, depressive symptoms using the Hamilton Depression Rating Scale and Beck Depression Inventory, level of functioning using the Social and Occupational Functioning Assessment Scale, self-esteem using the Rosenberg Self-Esteem Scale, and quality of life was assessed using the EuroQol-5D. The reliability of DISC 12 was assessed by internal consistency using Cronbach's alpha coefficient and estimating the intercorrelation of items and corrected item-total correlations; interrater reliability and test-retest reliability were assessed using intraclass correlation coefficients at the item and subscale levels; and the concurrent validity of the DISC 12-K relative to the other assessment scales was assessed using Spearman's correlation coefficient.

RESULTS

All of the DISC 12-K subscales had high reliability. The validity was good for the Unfair Treatment and Stopping Self subscales, but only fair for the Overcoming Stigma and Positive Treatment subscales.

CONCLUSION

The Unfair Treatment and Stopping Self subscales of the new DISC 12-K are reliable and valid measures of stigma in patients with depressive disorders. Future studies are needed to test the validity of this scale in other mental disorders.

Sex differences in the genetic architecture of depression

The prevalence and clinical characteristics of depressive disorders differ between women and men; however, the genetic contribution to sex differences in depressive disorders has not been elucidated. To evaluate sex-specific differences in the genetic architecture of depression, whole exome sequencing of samples from 1000 patients (70.7% female) with depressive disorder was conducted. Control data from healthy individuals with no psychiatric disorder (n = 72, 26.4% female) and East-Asian subpopulation 1000 Genome Project data (n = 207, 50.7% female) were included. The genetic variation between men and women was directly compared using both qualitative and quantitative research designs. Qualitative analysis identified five genetic markers potentially associated with increased risk of depressive disorder in females, including three variants (rs201432982 within PDE4A, and rs62640397 and rs79442975 within FDX1L) mapping to chromosome 19p13.2 and two novel variants (rs820182 and rs820148) within MYO15B at the chromosome 17p25.1 locus. Depressed patients homozygous for these variants showed more severe depressive symptoms and higher suicidality than those who were not homozygotes (i.e., heterozygotes and homozygotes for the non-associated allele). Quantitative analysis demonstrated that the genetic burden of protein-truncating and deleterious variants was higher in males than females, even after permutation testing. Our study provides novel genetic evidence that the higher prevalence of depressive disorders in women may be attributable to inherited variants.