Effectiveness of vortioxetine for major depressive disorder in real-world clinical practice: US cohort results from the global RELIEVE study

INTRODUCTION

Effective treatment of major depressive disorder (MDD) involves addressing both depressive and functional symptoms, increasing patients' overall sense of well-being and quality of life (QoL).

METHODS

RELIEVE was an international observational, prospective study in patients ≥18 years with a current diagnosis of a major depressive episode (MDE) initiating vortioxetine in routine clinical practice; outcomes for the cohort of participants from the United States are presented here. Functioning was assessed at weeks 12 and 24 versus baseline using the Sheehan Disability Scale (SDS). Secondary effectiveness analyses assessed changes from baseline to weeks 12 and 24 in functioning, depression severity, cognitive symptoms, sexual function, and QoL.

RESULTS

244 participants had an average of 8.2 previous MDEs; mean duration of their current MDE at baseline was 93.5 weeks. Vortioxetine was used as second- or later-line treatment for 80.5% of participants. Least-squares mean (SE) SDS total score significantly decreased from baseline by 7.19 (0.52) points at week 12 and 8.19 (0.56) points at week 24 (p < 0.0001 for both). Significant improvements were also reflected across SDS subscores, depression severity, cognitive function, sexual function, and QoL. Healthcare resource utilization and productivity parameters also improved. Adverse events were observed in 21.8% of patients, with nausea being the most common (7.3%).

CONCLUSION

This real-world study demonstrated improvements in functioning, depressive symptoms, and cognitive function in patients with MDD treated with vortioxetine in routine clinical practice in the cohort of patients enrolled in the United States. Outcomes were consistent with the efficacy and safety profile of vortioxetine in randomized controlled trials.

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

BACKGROUND

Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base.

METHODS

We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder.

RESULTS

We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents.

CONCLUSIONS

Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.

Effectiveness of vortioxetine in real-world clinical practice: Interim results from the relieve study

Introduction

Vortioxetine has demonstrated sustained efficacy and favorable safety profile in multiple clinical trials.

Objectives

This study aims to describe the effectiveness and safety of vortioxetine in real-world clinical practice.

Methods

RELIEVE is a prospective, multi-national, observational cohort study of outpatients initiating vortioxetine treatment for MDD at physician’s discretion and followed for 6 months. Data were collected at routine clinical visits. The primary outcome was functioning measured by Sheehan Disability Scale (SDS). Depressive symptoms measured by Patient Health Questionnaire 9-item (PHQ-9), cognitive symptoms measured by PDQ-5 and DSST were key secondary outcomes. Safety outcomes including adverse events were reported. This interim analysis presents results of 527 patients who completed the study and were followed for 6 months. Mixed models of repeated measures were used to assess improvements between baseline and month 6, adjusted for relevant confounders.

Results

A total of 527 patients (mean age, 50.2 years, 65% female) were enrolled from US, Canada, France and Italy, and included in the analysis. Mean SDS total score, PHQ-9, PDQ-5 scores decreased by 8.6, 7.4 and 4.7 respectively from baseline to last visit. Mean DSST score improved by 6.5 from baseline to last visit. Patients’ overall functioning and quality of life significantly improved, sick leave days and underproductive days (both absenteeism and presenteeism) decreased over the entire follow up period. The overall incidence of adverse events(AE) was 25%, with the most common AEs being nausea and headache.

Conclusions

The results confirm the effectiveness and good tolerability of vortioxetine in a broad range of patients in routine clinical practice.

Conflict of interest

Dr. Mattingly has served as researcher, consultant or speaker for Akili, Alcobra, Alkermes, Allergan, Axsome, Boehringer, Forum, Genentech, Jansen, Lundbeck, Medgenics, Merck, Neos, NLS Pharma, Otsuka, Reckitt Benckiser, Roche, Sage, Shire, Sunovion, Supe

The impact of cognitive challenges in major depression: the role of the primary care physician

Nearly 1 in 5 Americans will struggle with major depression in their lives; some will have recurring bouts. Recent psychiatric research has given new attention to the prevalence of cognitive deficits in major depression and the impact such deficits have on remission and overall life functioning. When depression is partially treated i.e., leaving residual symptoms, patients have higher rates of relapse and lower functional outcomes. Impaired cognitive functioning is a frequent residual symptom, persisting in about 45% of patients even when emotional symptoms have improved, and results in a disproportionate share of the functional impairment, particularly in the workplace. Patients with depression have disrupted circuitry in brain regions responsible for cognition and it is therefore important to screen depressed patients for cognitive as well as emotional symptoms. Cognitive dysfunction should be evaluated in every mood disordered patient with validated self-report scales such as the Patient Health Questionnaire-9 or the Beck Depression Inventory and objective measures of cognitive function are also very very useful. Two easily administered tests are the Trails B Test and the Digit Symbol Substitution Test. Each take less than two minutes and measure working memory, executive function, and processing speed and can track cognitive improvement in depressed patients. Treatment of cognitive dysfunction in major depression is complicated by the 'serotonin conundrum': SSRI's frequently do not treat to full remission, and can cause cognitive blunting-actually adding to cognitive problems. Based on recent data including results from a recently completed meta-analysis by McIntyre and colleagues, an evidence-based algorithm for treating cognitive symptoms in depression is presented. A hierarchy of antidepressants and augmentation strategies based on the best available evidence is discussed. In conclusion, cognitive symptoms in major depressive disorder have been recognized as a target of therapeutic improvement by the FDA and have become a focus of clinical importance.

Response/remission with guanfacine extended-release and psychostimulants in children and adolescents with attention-deficit/hyperactivity disorder

OBJECTIVE

In this post hoc analysis, we assessed whether guanfacine extended-release (GXR) adjunctive to a psychostimulant resulted in greater response and remission rates than placebo + psychostimulant in children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHOD

In this 9-week, double-blind, placebo-controlled dose-optimization study, participants (N = 461) aged 6 to 17 years with suboptimal response to psychostimulants were randomized to GXR on awakening (AM) + psychostimulant, GXR at bedtime (PM) + psychostimulant, or placebo + psychostimulant.

RESULTS

At the final on-treatment assessment, more participants in both GXR + psychostimulant groups versus the placebo + psychostimulant group achieved response as assessed by 2 criteria: reduction from baseline in ADHD Rating Scale IV (ADHD-RS-IV) total score (1) ≥40% (GXR AM + psychostimulant = 69.8%, GXR PM + psychostimulant = 70.3%, versus placebo + psychostimulant = 57.9%; p = .032 and p = .026, respectively), or (2) ≥50% (63.1%, 64.9%, versus 43.4%; p <.001 for both). Results were similar for symptomatic remission (ADHD-RS-IV total score ≤18; 61.1%, 62.2%, versus 46.1%; p = .010 and p = .005, respectively) and syndromal remission (symptomatic remission plus Clinical Global Impressions of Severity of Illness score ≤2). The most common treatment-emergent adverse events in participants receiving GXR + psychostimulant were headache (21.2%) and somnolence (13.6%).

CONCLUSION

GXR + psychostimulant treatment resulted in a greater percentage of participants meeting stringent criteria for response and remission compared with placebo + psychostimulant. The adverse event profile of adjunctive therapy was consistent with known effects of either treatment alone. Clinical trial registration information-Efficacy and Safety of SPD503 in Combination With Psychostimulants; http://clinicaltrials.gov/; NCT00734578.

Challenges in identifying and managing attention-deficit/hyperactivity disorder in adults in the primary care setting: a review of the literature

OBJECTIVE

To examine how to screen for and establish a correct diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults and to identify the outcomes associated with untreated ADHD.

DATA SOURCES

PubMed was searched using the key words ADHD, adult, diagnosis, and primary care from the years 1999 to 2009.

STUDY SELECTION

This search produced 50 publications.

DATA EXTRACTION

Publications were screened for data specific to the diagnosis or management of adult patients with ADHD in the primary care setting.

DATA SYNTHESIS

The estimated prevalence of ADHD in adults throughout the United States is 4.4% or approximately 10 million adults. Adults with ADHD by definition must experience impairment from the symptoms of ADHD in at least 2 areas of their life. Despite significant impairment, only 1 in 10 adults with ADHD have received ADHD treatment within the past year. Given the high rates of undertreatment, primary care physicians, who provide much of the general adult mental health care in the United States, are increasingly charged with making the diagnosis of ADHD in adults. ADHD symptoms are often masked by comorbid psychiatric conditions or patient adaptations such as choice of occupation. One of the ADHD assessment tools, a short 6-item screener, can simplify identification and management of ADHD in adults and help identify which patients may require further evaluation.

CONCLUSIONS

Primary care physicians should consult with other members of the health care community such as psychiatrists and psychologists when necessary, but should also develop a level of comfort with diagnosing and treating ADHD.

A practical guide to recognition and diagnosis of ADHD in adults in the primary care setting

Attention-deficit/hyperactivity disorder (ADHD) is commonly perceived as a childhood disorder, but ADHD symptoms can persist into adulthood. The symptoms, deficits, and consequences associated with adult ADHD can have a profound impact on the daily lives of patients and their families. Self-awareness of ADHD symptoms can sometimes be difficult for adults who have lived with these symptoms since childhood. Attention-deficit/hyperactivity disorder is highly comorbid with other psychiatric disorders, and physicians should maintain a high index of suspicion and integrate screening for ADHD when they feel that psychiatric evaluation is indicated in their adult patients. Attention-deficit/hyperactivity disorder can be screened for in as little as 3 to 5 minutes with a variety of self-report or physician-implemented scales. An accurate diagnosis of ADHD in adults requires a comprehensive clinical interview that reviews representative symptoms starting in childhood that continue to cause impairment into adulthood. It is often helpful to interview or obtain information from family, friends, coworkers, or school records. With increasing understanding of ADHD in adults, the recent development of adult-specific diagnostic scales promises further improvement in the standard of care for this disorder. Appropriate treatment of ADHD in adults can provide dramatic symptomatic improvement with some of the largest treatment effects of any medical condition.

Quincke's disease: nonhereditary angioneurotic edema of the uvula

We report two cases of Quincke's disease, an isolated form of angioneurotic edema involving the uvula that is induced by several factors, including foods, drugs, and inhalants. Although Quincke's disease has prominent oral manifestations, it has only rarely been described in the dental literature. The rapid onset and progression of the disorder, combined with the risk of respiratory compromise, may result in a serious medial emergency. Clinical manifestations include a nonerythematous swollen uvula, fullness in the throat, and signs of airway obstruction. A hereditary form of angioneurotic edema is associated with a biochemical defect; this must be differentiated from nonhereditary, localized forms such as Quincke's disease to determine appropriate treatment and predict prognosis. Clinical features and laboratory tests can distinguish hereditary angioneurotic edema from the nonhereditary form.

Combined use of labetalol and nifedipine in controlling the cardiovascular response from ECT

Serious cardiac complications have been reported to occur in elderly depressed patients during a course of electroconvulsive therapy (ECT). As a result, cardiac medications are being used more often to dampen the cardiovascular response that occurs during an ECT treatment. Specifically, labetalol (a mixed alpha- and beta-blocker) has been shown to effectively control the heart rate during ECT. However, on occasion, patients may still exhibit sustained elevations of blood pressure during ECT when receiving labetalol. The optimum clinical management of these patients is unclear. The authors report on the safety and efficacy of combining nifedipine with labetalol to control blood pressure during ECT in ten elderly patients whose blood pressures were not adequately controlled by labetalol alone. No adverse effects were noted, nor did nifedipine appear to shorten seizure duration.

ECT-induced interictal delirium in patients with a history of a CVA

Earlier works have documented a high incidence of affective disorders in patients with a history of a cerebrovascular accident (CVA). In general, electroconvulsive therapy (ECT) has been reported to be effective in treating depressed patients with a history of CVA. Recent works have shown that preexisting structural brain changes may predispose patients to develop interictal ECT-induced delirium. However, the incidence of ECT-induced interictal delirium in patients with a history of CVA has not been directly studied. In this pilot study, the authors examined the incidence of ECT-induced interictal delirium in 14 depressed CVA patients compared with 14 elderly depressed controls (without a history of CVA). Interestingly, the overall incidence of delirium was identical in both groups (28.5%). However, consistent with previous works, some patients who had had a recent CVA involving the caudate nucleus appeared more likely to develop delirium. Thirteen of the 14 depressed CVA patients (92%) showed a moderate to significant improvement in their depressive symptoms from ECT. None of the patients developed significant cardiac complications during ECT.

Multiple sclerosis and ECT: possible value of gadolinium-enhanced magnetic resonance scans for identifying high-risk patients

Electroconvulsive therapy (ECT) has been used effectively in treating depressed patients with multiple sclerosis (MS). However, several reports have observed that some patients with MS may suffer neurological deterioration during ECT. The authors describe the outcomes of 3 depressed patients with MS who were treated with ECT. Consistent with previous works, ECT effectively treated the psychiatric symptoms; however, 1 patient deteriorated neurologically during ECT. The brain MRI findings and clinical courses of all 3 patients are discussed, along with the possible value of gadolinium-contrast MRI scans for identifying high-risk patients.

Determining therapeutic efficacy in recurrent herpes labialis by lesion size analysis

We devised an experimental model for the analysis of therapeutic efficacy of topical medications for recurrent herpes labialis with a double-blind, placebo-controlled format. Rigid prestudy screening evaluations allowed the enrollment of a homogeneous starting population with characteristic herpetic reactivation in an early stage. Using precise measurements of lesion area for a 5-day period, we evaluated the effects of a novel medication containing tannic acid, which has demonstrated impressive inhibitory effects on herpes simplex virus in many recent studies, and salicylic acid, which has rapid absorption kinetics and substantial topical anti-inflammatory and keratin-disrupting properties. Using parametric and nonparametric tests, we studied differences in mean lesion size and used these measurements to evaluate objective and clinically applicable improvement criteria. Although there were no significant differences in mean lesion size at presentation (day 1) between the active medication and placebo groups, the former demonstrated significantly smaller lesions at days 2 through 5 (p less than 0.05). By day 5, 10 of 14 treated subjects showed improvement as defined by a 25% reduction in lesion size compared with day 1, in contrast to only 2 of 12 subjects in the placebo group (p = 0.0079, Fisher's Exact Test). This model can be employed in the evaluation of topical antiviral agents for herpes labialis in a healthy population, because it standardizes criteria for subject enrollment and provides objective and reproducible measurements of therapeutic efficacy.

Regional localization of RNA and protein metabolism in Schwann cells in vivo

Schwann cells, which form and maintain extensive myelin sheaths, have the bulk of their lipid and protein synthesis restricted to the compact 'perinuclear' zone at the centre of the internode. Using teased fibre and quantitative electron microscopical autoradiography, we demonstrated that additional protein synthesis takes place in the lengthy processes of Schwann cell cytoplasm. This 'so-called' superficial cytoplasmic channel network forms a branching and anastomozing array that stretches between the perinuclear region and the distant paranodes. Protein synthesis apparently does not extend from this surface network into the Schmidt-Lanterman incisures or paranodal loops that circumscribe compact myelin. To maintain protein synthesis in these lengthy processes, Schwann cells transport a portion of their RNA along the superficial cytoplasmic channels at a rate (0.1 mm per day) that appears to be slightly lower than the transport rate reported for RNA along dendrites of hippocampal neurons in culture (0.5 mm per day). Nearly a week is required for labelled RNA to be transported from the Schwann cell nucleus to the paranodal terminals of the longer channels. The existence of this extended protein synthesis is not limited to myelinating Schwann cells. Schwann cell processes associated with small calibre axons also appear to synthesize some of their own proteins as the RNA needed to catalyze local translational events is transported into these processes.