Assessment and Management of Cognitive and Psychosocial Dysfunctions in Patients With Major Depressive Disorder: A Clinical Review

Rethinking the role of trazodone in the different depressive dimensions

INTRODUCTION

The efficacy of trazodone for several psychopathologic dimensions of depression has been shown in the literature. Trazodone has been widely used in some clinical contexts (e.g. for insomnia and depression in the elderly). However, the role of trazodone in several aspects of depression is not well known.

AREA COVERED

Eight experts from academic and medical centers across Italy met to identify the difficulties and barriers faced in daily clinical practice in the assessment and management of major depressive disorder and how the use of trazodone could address some unmet needs. The objective of the expert meetings and the present document was to increase knowledge of particular areas of treatment with trazodone.

EXPERT OPINION

Evidence of the role of trazodone in patients affected by major depressive disorder with anxiety symptoms, insomnia, agitation, cognitive deficits, alcohol use disorders, physical comorbidities, and suicide risk has been identified, showing the effectiveness of trazodone in different presentations of major depressive disorder. The main characteristics of patients with depression for whom trazodone seems to be most effective have been identified, providing clinicians with information on possible uses of this drug in such population of patients.

One-year efficacy of a lifestyle behavioural intervention on physical and mental health in people with severe mental disorders: results from a randomized controlled trial

This multicentric randomized controlled trial (RCT), carried out in six Italian University mental health sites, aims to test the efficacy of a six-month psychosocial intervention (LYFESTYLE) on Body Mass Index (BMI), body weight, waist circumference, fasting glucose, triglycerides, cholesterol, Framingham and HOmeostasis Model Assessment of insulin resistance (HOMA-IR) indexes in patients with schizophrenia, bipolar disorder, and major depression. Moreover, the efficacy of the intervention has also been tested on several other physical and mental health domains. Patients were randomly allocated to receive the six-month experimental intervention (LIFESTYLE) or a behavioural control intervention. All enrolled patients were assessed at baseline and after one year. We recruited 401 patients (206 in the experimental and 195 in the control group) with a diagnosis of schizophrenia or other psychotic disorder (29.9%), bipolar disorder (43.3%), or major depression (26.9%). At one year, patients receiving the experimental intervention reported an improvement in body mass index, body weight, waist circumference, HOMA-IR index, anxiety and depressive symptoms and in quality of life. Our findings confirm the efficacy of the LIFESTYLE intervention in improving physical and mental health-related outcomes in patients with severe mental illnesses after one year.

If you feel you can't, you won't: the role of subjective and objective cognitive competence on psychosocial functioning in depression

BACKGROUND

The purpose of this exploratory study is to examine the role of sociodemographic, clinical, and cognitive - both objective and subjective - factors in overall and in specific domains of psychosocial functioning, in patients with depression at different clinical states of the disease (remitted and non-remitted).

METHODS

A sample of 325 patients with major depressive disorder, 117 in remission and 208 in non-remission, were assessed with a semi-structured interview collecting sociodemographic, clinical, cognitive (with neuropsychological tests and the Perceived Deficit Questionnaire), and functional (Functioning Assessment Short Test) characteristics. Backward regression models were conducted to determine associations of global and specific areas of functioning with independent factors, for both clinical states.

RESULTS

Residual depressive symptomatology and self-appraisal of executive competence were significantly associated with psychosocial functioning in remitted patients, in overall and some subdomains of functioning, particularly cognitive and interpersonal areas. While depressive symptoms, executive deficits and self-appraisal of executive function were significantly related to functional outcomes in non-remitted patients, both in overall functioning and in most of subdomains.

DISCUSSION

This study evidences the strong association of one's appraisal of executive competence with psychosocial functioning, together with depressive symptoms, both in remitted and non-remitted patients with depression. Therefore, to achieve full recovery, clinical management of patients should tackle not only the relief of core depressive symptoms, but also the cognitive ones, both those that are objectified with neuropsychological tests and those that are reported by the patients themselves.

Factors associated with objective and subjective cognitive impairment in Chinese patients with acute major depressive disorder

BACKGROUND

Patients diagnosed withmajor depressive disorder (MDD) usually experience impaired cognitive functioning, which might negatively impact their clinical and functional outcomes. This study aimed to investigate the association of specific clinical factors with cognitive dysfunction in a group of MDD patients.

METHODS

A total of 75 subjects diagnosed with recurrent MDD were evaluated during the acute stage. Their cognitive functions were assessed using the THINC-integrated tool (THINC-it) for attention/alertness, processing speed, executive function, and working memory. Clinical psychiatric evaluations, such as the Hamilton Anxiety Scale (HAM-A), the Young Mania Rating Scale (YMRS), the Hamilton Depression Scale (HAM-D), and the Pittsburgh Sleep Quality Index(PSQI), were used to assess patients' levels of anxiety, depression and sleeping problems. The investigated clinical variables were age, years of education, age at onset, number of depressive episodes, disease duration, presence of depressive and anxiety symptoms, sleep problems, and number of hospitalizations.

RESULTS

The results revealed that significant differences were observed between the two groups in the THINC-it total scores, Spotter, Codebreaker, Trails, and PDQ-5-D scores (P < 0.001). The THINC-it total scores, Spotter, Codebreaker, Trails, and Symbol Check were significantly associated with age and age at onset(P < 0.01). In addition, regression analysis found that years of education was positively associated with the Codebreaker total scores (P < 0.05). the THINC-it total scores, Symbol Check, Trails, and Codebreaker were correlated with the HAM-D total scores(P < 0.05). Additionally, the THINC-it total scores, Symbol Check, PDQ-5-D and Codebreaker significantly correlated with the PSQI total scores (P < 0.05).

CONCLUSION

We found a significant statistical association between almost all cognitive domains and different clinical aspects in depressive disorder, such asage, age at onset, severity of depression, years of education, and sleep problems. Additionally, education was shown to be a protective factor against processing speed impairments. Special considerations of these factors might help outline better management strategies to improve cognitive functions in MDD patients.

Cognitive Decline and Its Associated Factors in Patients with Major Depressive Disorder

Background: Major Depressive Disorder (MDD) is a significant and common mental health problem occurring worldwide. Cognitive decline is frequently observed during acute and residual phases of MDD, contributing significantly to functional impairment. The aim of this study was to determine the clinical profile and correlates of cognitive decline amongst adult outpatients with MDD. Methods: The survey was cross-sectional in design. A systematic random sampling method was used to recruit patients. Confirmation of MDD was achieved by using the Mini International Neuropsychiatric Interview (M.I.N.I 7.0). Cognitive decline was measured using the Montreal Cognitive Assessment (MoCA). Descriptive analysis was performed, followed by univariate and multiple logistic regression analyses. Results: Out of 245 patients, 32.7% (n = 80, 95% CI: 26.7, 38.6) had cognitive decline. Multiple logistic regression showed the existence of cognitive decline amongst MDD patients, which was significantly associated with those having secondary and lower levels of education (OR: 6.09; 95% CI: 2.82, 13.16; p < 0.001), five or more depressive episodes (OR: 8.93; 95% CI: 3.24, 24.67; p < 0.001), treatment non-compliance (OR: 3.48; 95% CI: 1.40, 6.59; p = 0.003), and medical comorbidity (OR: 2.74; 95% CI: 1.46, 5.18; p = 0.002). Conclusions: Cognitive decline is a prevalent condition among outpatients with MDD. Clinicians need to be cognizant about measures of cognition and related risk factors. Timely control of both depression and medical comorbidities would be a reasonable approach to improve functional outcomes in MDD patients.

Psychiatric rehabilitation and cognitive deficit for treatment-resistant depression

Patients with TRD often experience persistent impairment of affective, psychosocial, and cognitive function, which impedes their recovery. The continuation of pharmacotherapy for patients with TRD remains the cornerstone of functional recovery. Cognitive dysfunction is prevalent in patients with MDD and may make patients' depressive symptoms and psychosocial functioning worse, even in the remitted stage of illness. Deficits can manifest not only in specific cognitive domains but also in global cognitive function, which may reflect underlying persistent pathophysiological changes. Compared with nontreatment-resistant patients with MDD, patients with TRD exhibit greater subjective and objective cognitive impairment, which possibly contributes to a greater adverse impact on daily functioning. Cognitive and psychosocial remission should be a goal in treating MDD. How to appropriately and individualized perform pharmacological intervention, psychotherapy, neuromodulation, cognitive remediation or other rehabilitation treatment programs is a critical step to achieve our goal. Integrating multiple interventions that engage multiple physiological systems with a multidisciplinary team warrants increased attention, and personalized therapeutic programs may facilitate the complete restoration of patients' everyday functioning.

Depression in Major Neurodegenerative Diseases and Strokes: A Critical Review of Similarities and Differences among Neurological Disorders

Depression and anxiety are highly prevalent in most neurological disorders and can have a major impact on the patient's disability and quality of life. However, mostly due to the heterogeneity of symptoms and the complexity of the underlying comorbidities, depression can be difficult to diagnose, resulting in limited recognition and in undertreatment. The early detection and treatment of depression simultaneously with the neurological disorder is key to avoiding deterioration and further disability. Although the neurologist should be able to identify and treat depression initially, a neuropsychiatry team should be available for severe cases and those who are unresponsive to treatment. Neurologists should be also aware that in neurodegenerative diseases, such as Alzheimer's or Parkinson's, different depression symptoms could develop at different stages of the disease. The treatment options for depression in neurological diseases include drugs, cognitive-behavioral therapy, and somatic interventions, among others, but often, the evidence-based efficacy is limited and the results are highly variable. Here, we review recent research on the diagnosis and treatment of depression in the context of Alzheimer's disease, Parkinson's disease, and strokes, with the aim of identifying common approaches and solutions for its initial management by the neurologist.

Validation of the THINC-It Tool for Assessment of Cognitive Impairment in Patients with Bipolar Depression

BACKGROUND

Cognitive impairment is one of the core features of bipolar depression. A unified, reliable, and valid assessment tool is key to screening and assessing cognitive impairment. The THINC-Integrated Tool (THINC-it) is a simple and quick battery for screening cognitive impairment in patients with major depressive disorder. However, the use of the tool has not been validated in patients with bipolar depression.

METHODS

The cognitive functions of 120 patients with bipolar depression and 100 healthy controls were evaluated using the THINC-it tool including Spotter, Symbol Check, Codebreaker, Trials, and the only one subjective test (PDQ-5-D) and five corresponding standard tests. A psychometric analysis of the THINC-it tool was performed.

RESULTS

The overall Cronbach's alpha coefficient of the THINC-it tool was 0.815. The intra-group correlation coefficient (ICC) of retest reliability ranged from 0.571 to 0.854 (P<0.001), while the correlation r of parallel validity ranged from 0.291 to 0.921 (P<0.001). There were significant differences in the two groups Z-scores of THINC-it total score, Spotter, Codebreaker, Trails, and PDQ-5-D (P<0.05). Construct validity was analyzed using exploratory factor analysis (EFA). The Kaiser-Meyer-Olkin (KMO) value was 0.749. Using Bartlett's Sphericity test, the χ ² (10) value was 198.257 (P<0.001). The factor loading coefficients of Spotter, Symbol Check, Codebreaker, and Trails on the common factor 1 were -0.724, 0.748, 0.824, and -0.717, respectively, and the factor loading coefficient of PDQ-5-D on the common factor 2 was 0.957. Results revealed that the correlation coefficient of the two common factors was 0.125.

CONCLUSION

The THINC-it tool has good reliability and validity in assessing patients with bipolar depression.

The Relationship between Mental Disorders and the COVID-19 Pandemic—Course, Risk Factors, and Potential Consequences

In this review the authors discuss that COVID-19 has already had a direct impact on the physical health of many people and that it appears to have put at risk the mental health of large populations. In this review, we also discuss the relationship between mental disorders and the SARS-CoV-2 infection. We convey the disorders’ risk factors and the more serious mental disorder consequences of COVID-19. People with mental health disorders could be more susceptible to the emotional responses brought on by the COVID-19 epidemic. The COVID-19 pandemic may adversely influence the mental health of patients with already diagnosed mental disorders. For the aim of dealing better with the psychological problems of people afflicted by the COVID-19 pandemic, new psychological procedures are required.

Transtorno Depressivo Maior: Um Estudo Comparativo sobre Cognição Socioemocional e Funções Executivas

Resumo O objetivo deste estudo foi avaliar a cognição socioemocional e as funções executivas em pacientes com Transtorno Depressivo Maior unipolar. A amostra incluiu 22 pacientes entre 36 e 93 anos de idade (M = 59,32; DP = 12,89) e 23 indivíduos controles entre 30 e 81 anos de idade (M = 63,00; DP = 13,56). Além de dados demográficos, foram avaliados sintomas de ansiedade e de depressão, empatia, teoria da mente, reconhecimento de emoções, controle inibitório, flexibilidade cognitiva e fluência verbal. Não houve diferença estatística significativa entre os grupos quanto à idade e à escolaridade. Os pacientes apresentaram significativamente mais ansiedade, depressão e angústia pessoal do que os controles. Indivíduos com sintomas depressivos mais graves apresentaram menor velocidade de processamento.

Geriatric Depression and Cognitive Impairment-An Update

BACKGROUND

Depression and cognitive impairment often coexist in older adults. The relation between depression and cognitive impairment is complex. The objective of this article is to review recent literature on cognitive impairment in older adults with depression and provide clinicians an update.

METHODS

We searched PubMed, Google Scholar, Science Direct, and Psych Info for the articles published in the English language related to late-life depression (LLD)/geriatric depression and cognitive impairment. We considered original research articles, relevant systematic reviews, chapters, and important conceptual articles published in the last 9 years (2011-2019). We selected relevant articles for this narrative review.

CONCLUSION

The concept pseudodementia, indicating depression with cognitive impairment mimicking dementia, is now seen only as a historical concept. The current literature strongly agrees with fact that cognitive deficits often exist in LLD. The cognitive deficits in depression were initially seen as trait marker; however, some recent studies suggest that cognitive deficits persist even in the remission phase. There is heterogeneity among the studies in terms of the nature of the cognitive deficits, but higher number of studies reported impairment in attention and executive function. LLD with cognitive deficits is at a higher risk of progression to dementia. In older adults, depression with cognitive impairments requires a comprehensive evaluation. Electroencephalography, event-related potentials, fluorodeoxyglucose-positron emission tomography, amyloid positron emission tomography, and CSF amyloid will supplement clinical evaluation in differentiating functional depressive disorder with cognitive impairment from depression with an underlying degenerative condition.

The alteration of cognitive function networks in remitted patients with major depressive disorder: an independent component analysis

INTRODUCTION

Dysfunctional connectivity of resting-state functional networks has been observed in patients with major depressive disorder (MDD), particularly in cognitive function networks including the central executive network (CEN), default mode network (DMN) and salience network (SN). Findings from studies examining how aberrant functional connectivity (FC) changed after antidepressant treatment, however, have been inconsistent. Thus, the purpose of the present study was to explore potential mechanisms of altered cognitive function networks during resting-state between remitted major depressive disorder (rMDD) patients and healthy controls (HCs) and furthermore, the relationship between dysfunctional connectivity patterns in rMDD and clinical symptoms.

METHODOLOGY

In this study, 19 HCs and 19 rMDD patients were recruited for resting-state functional magnetic resonance imaging (fMRI) scanning. FC was evaluated with independent component analysis for CEN, DMN and SN. Two sample t tests were conducted to compare differences between rMDD and HCs. A Pearson correlation analysis was also performed to examine the relationship between connectivity of networks and cognitive function scores and clinical symptoms.

RESULTS

Compared to healthy controls, remitted patients showed lower connectivity in CEN, mostly in the superior frontal gyrus (SFG), middle frontal gyrus (MFG), inferior parietal lobule (IPL) and part of the supramarginal gyrus (SMG). Conversely, the bilateral insula, part of the SMG (a key node of the CEN) and dorsal anterior cingulate cortex (dACC) of the DMN showed higher connectivity in rMDD patients. Pearson correlation results demonstrated that connectivity of the right IPL in CEN was positively correlated with cognitive function scores, and connectivity of the left insula was negatively correlated with BDI scores.

CONCLUSIONS

Though rMDD patients reached the standard of clinal remission, unique impairments of FC in cognitive function networks remained. Aberrant FC between cognitive function networks responsible for executive control was observed in rMDD and may be associated with residual clinical symptoms.

Diagnosis, Clinical Features, and Therapeutic Implications of Agitated Depression

Agitated "unipolar" depression is a clinical entity characterized by excitement together with depressed mood during the same episode. The clinical picture of agitated "unipolar" depression is characterized by a depressed and anxious mood with inner, psychic agitation, whereas motor agitation may or may not be present. Some investigators have conceptualized this disorder as a mixed affective state, laying on the bipolar disorder spectrum, but controversies still persist. The diagnosis of agitated "unipolar" depression has important prognostic and therapeutic implications, with many clinicians reporting difficulties to adequately diagnose and treat it.

Reliability and Validity of THINC-it in Evaluating Cognitive Function of Patients with Bipolar Depression

PURPOSE

The THINC-integrated tool (THINC-it) as a brief screening tool can assesses cognitive impairment in patients with major depressive depression (MDD). Here, we aim to evaluate the reliability and validity of the THINC-it in a bipolar depression (BD-D) group in comparison with a healthy control (HC) group.

MATERIALS AND METHODS

Both groups were matched according to age, gender, years of education, and IQ. All participants completed the THINC-it test, including Spotter, Symbol Check, Codebreaker, Trails, and the Perceived Deficits Questionnaire for Depression-5-item (PDQ-5-D). The concurrent validity and internal consistency of the THINC-it test were analyzed, and 30 healthy controls were randomly sampled to retest THINC-it to verify the reliability of the THINC-it retest. The correlation between THINC-it and Hamilton Depression Scale (HAMD-17) and Sheehan Disability Scale (SDS) was also analyzed.

RESULTS

Fifty-eight patients with BD-D and 61 HCs were included for final analysis. There were significant mean difference (MD) standard errors (SE) between two groups in PDQ-5-D, Spotter and Codebreaker (all P<0.01), Trails (P=0.015). There was no significant difference in Symbol Check (MD (SE)=-0.01 (0.18), P=0.938; 95% CI=-0.38 to 0.35). The Cronbach's α of PDQ-5-D was 0.640. The intraclass correlation coefficient (ICC) was between 0.440 and 0.757. The highest concurrent validity was PDQ-5-D (r=0.812, P<0.001). PDQ-5-D was positively correlated with HAMD-17 and SDS score (P<0.01). The objective test had no significant correlation with HAMD-17 and SDS scores (P>0.05).

CONCLUSION

This study found that THINC-it can accurately present the cognitive impairment of patients with BD-D. It can be potentially applied in assessing the cognitive function of patients with BD-D although Symbol Check may not accurately reflect the level of cognitive function. The concurrent validity and retest reliability are lower than expected, we need to further increase the sample size to study.

Psychoeducational Intervention for Perinatal Depression: Study Protocol of a Randomized Controlled Trial

Perinatal depression (PD) is a severe and disabling condition impacting negatively on children in terms of adverse neonatal outcomes and on the well-being of women and their families. All pregnant women attending the unit of Gynecology and Obstetrics Service of the University of Campania "L. Vanvitelli" will be screened for PD using the Edinburgh Postpartum Depression Scale (EPDS). Women with a score ≥10 at the EPDS will be invited to receive a full psychiatric assessment. The required sample size is of 126 women with PD which will be randomly allocated to either an experimental group, receiving a uni-familiar psychoeducational intervention, or to a control group, receiving the Best Treatment Option (BTO). Patients will be evaluated through several assessment instruments: Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Global Assessment of Functioning (GAF), Clinical Global Impression (CGI), Manchester Short Assessment of Quality of Life (MANSA), Family Assessment Device (FAD), Family Coping Questionnaire (FCQ), and Pattern of Care Schedule (PCS). Patients will be evaluated at baseline, 3, 6, 9, and 12 months post-randomization. The severity of depressive symptoms at the HAM-D scale has been selected as primary outcome. Other outcome measures include improvement in the severity of anxiety symptoms, of global and personal functioning, an improvement in family members' coping strategies and in the level of quality of life. It has been highlighted the importance of developing screening and treating programs for PD, and our study will use rigorous study design to evaluate the efficacy of the adaption of a well-known family psychoeducational model to the treatment of PD. The aims of present trial are to: (1) develop an informative package for pregnant women with PD; (2) promote a screening programme for PD; (3) identify those (socio-demographic and pregnancy-related environmental) factors associated with a higher risk to develop a perinatal or postnatal depression; (4) evaluate the efficacy of a new experimental psychoeducational intervention in reducing the depressive symptoms during pregnancy compared to the BTO.