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Stahl ST, Kazan J, Lazzari T, Krafty RT, Reynolds CF, Rollman BL, Smagula SF, Gebara MA. Risk for Complicated Grief After the COVID-19 Death of a Marital Partner in Late Life. Am J Geriatr Psychiatry 2024; 32:386-391. [PMID: 37968160 PMCID: PMC10922502 DOI: 10.1016/j.jagp.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To identify 1) complicated grief symptom clusters among acutely-bereaved older adults who have lost a spouse to COVID-19 and 2) if spousal death due to COVID-19 increased risk of developing probable PGD METHODS: Eighty adults participating in a randomized controlled trial for depression prevention (mean age [± SD] = 70.4 [6.6]) completed the Inventory of Complicated Grief, every 3 months over a maximum of 15 months. Twenty-four percent (n = 19) of participants lost a spouse to COVID-19; 76% (n = 61) lost a spouse to other causes of death. Adjusted linear regression examined the associations between COVID-19 bereavement and six symptom clusters: yearning and preoccupation, anger and bitterness, shock and disbelief, estrangement from others, hallucinations, and behavior change. RESULTS Compared to the non-COVID-19 group, the COVID-19 bereaved group reported greater shock and disbelief, hallucinations of the deceased, and estrangement from others. COVID-19 death was also associated with higher risk for probable prolonged grief disorder (PGD) at 12 months (odds ratio = 4.38, p = 0.027). CONCLUSIONS Older adults who have lost a spouse to COVID-19 present with specific symptoms of distress and may eventually require clinical care for PGD.
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Affiliation(s)
- Sarah T Stahl
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA.
| | - Joseph Kazan
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Taylor Lazzari
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Robert T Krafty
- Department of Biostatistics (RTK), Emory University, Atlanta, GA
| | - Charles F Reynolds
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Rollman
- Department of Medicine (BLR), University of Pittsburgh, Pittsburgh, PA
| | - Stephen F Smagula
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Marie Anne Gebara
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
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Gebara MA, Brown PJ, Roose SP. Finally, New Hope for the Treatment of LLTRD. Am J Geriatr Psychiatry 2023; 31:1042-1044. [PMID: 37562991 DOI: 10.1016/j.jagp.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry (MAG), University of Pittsburgh, School of Medicine, Pittsburgh, PA.
| | - Patrick J Brown
- Department of Psychiatry (PJB, SPR), Columbia University College of Physicians and Surgeons, The New York State Psychiatric Institute, New York, NY
| | - Steven P Roose
- Department of Psychiatry (PJB, SPR), Columbia University College of Physicians and Surgeons, The New York State Psychiatric Institute, New York, NY
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Stahl ST, Kincman J, Karp JF, Anne Gebara M. Psychosocial interventions to improve adherence in depressed and anxious older adults prescribed antidepressant pharmacotherapy: a scoping review. Ther Adv Psychopharmacol 2023; 13:20451253231212322. [PMID: 38022838 PMCID: PMC10664420 DOI: 10.1177/20451253231212322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Medication nonadherence in depressed and anxious older adults is prevalent and associated with non-response to antidepressant pharmacotherapy. Evidence-based options to improve medication adherence are limited in this population. To review the state of the literature on the types and efficacy of psychosocial interventions for improving antidepressant pharmacotherapy adherence in depressed and anxious older adults. We conducted a scoping review according to PRISMA-ScR guidelines. PubMed/Medline and article references starting in 1980 up to 28 February 2023 were reviewed. Of the 710 records screened, 4 psychosocial interventions were included in the review. All studies included depressed older adults, and none included anxious older adults. Samples included racial and ethnic minorities and were primarily women. The psychosocial interventions consisted mainly of psychoeducation with usual care as the control comparison. Measures of antidepressant adherence included self-reported adherence or pill counting. Three of the four randomized controlled trials improved medication adherence rates and reduced depression symptom burden. Effective interventions exist for improving antidepressant medication adherence in depressed older adults. Improved adherence can reduce depression symptom burden. The lack of interventions for anxious older adults highlights the need to develop and deliver interventions for anxious older adults prescribed antidepressant pharmacotherapy.
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Affiliation(s)
- Sarah T. Stahl
- Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA, 15213, USA
| | - Joelle Kincman
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jordan F. Karp
- Department of Psychiatry, University of Arizona, Tucson AZ, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
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Vanderschelden B, Gebara MA, Oughli HA, Butters MA, Brown PJ, Farber NB, Flint AJ, Karp JF, Lavretsky H, Mulsant BH, Reynolds CF, Roose SP, Lenze EJ. Change in patient-centered outcomes of psychological well-being, sleep, and suicidality following treatment with intravenous ketamine for late-life treatment-resistant depression. Int J Geriatr Psychiatry 2023; 38:e5964. [PMID: 37392089 DOI: 10.1002/gps.5964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE To examine whether psychological well-being, sleep, and suicidality improved with treatment with intravenous (IV) ketamine for late-life treatment-resistant depression (TRD). METHODS This is an analysis of secondary outcomes in an open-label late-life TRD study examining the safety, tolerability, and feasibility of IV ketamine infusions. In the acute phase, participants (N = 25) aged 60 years or older received twice-a-week IV ketamine for 4 weeks. Then, participants with Montgomery-Asberg Depression Rating Scale (MADRS) total score <10 or ≥ 30% reduction from baseline proceeded to the continuation phase, an additional four weeks of once-a-week IV ketamine. The secondary outcomes analyzed here are based on the National Institute of Health Toolbox Psychological Well-Being subscales for Positive Affect and General Life Satisfaction, the Pittsburgh Sleep Quality Index, and the Scale for Suicidal Ideation. RESULTS Psychological well-being, sleep, and suicidality improved during the acute phase and those improvements were sustained during the continuation phase. Greater improvements in measures of psychological well-being and sleep were seen in participants who had greater improvements in MADRS scores and moved onto the continuation phase. All but one of the few participants with high suicidality at baseline improved; there were no cases of treatment-emergent suicidality. CONCLUSIONS Psychological well-being, sleep, and suicidality improved in participants with late-life TRD who received IV ketamine for 8 weeks. A future larger and longer controlled trial is needed to confirm and extend these findings. REGISTRATION ClinicalTrials.gov identifier: NCT04504175.
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Affiliation(s)
- Benjamin Vanderschelden
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hanadi Ajam Oughli
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
| | - Meryl A Butters
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick J Brown
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, New York, USA
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alastair J Flint
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Jordan F Karp
- Department of Psychiatry, University of Arizona, College of Medicine-Tucson, Tucson, Arizona, USA
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
| | - Benoit H Mulsant
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven P Roose
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, New York, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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Subramanian S, Oughli HA, Gebara MA, Palanca BJA, Lenze EJ. Treatment-Resistant Late-Life Depression: A Review of Clinical Features, Neuropsychology, Neurobiology, and Treatment. Psychiatr Clin North Am 2023; 46:371-389. [PMID: 37149351 DOI: 10.1016/j.psc.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Major depression is common in older adults (≥ 60 years of age), termed late-life depression (LLD). Up to 30% of these patients will have treatment-resistant late-life depression (TRLLD), defined as depression that persists despite two adequate antidepressant trials. TRLLD is challenging for clinicians, given several etiological factors (eg, neurocognitive conditions, medical comorbidities, anxiety, and sleep disruption). Proper assessment and management is critical, as individuals with TRLLD often present in medical settings and suffer from cognitive decline and other marks of accelerated aging. This article serves as an evidence-based guide for medical practitioners who encounter TRLLD in their practice.
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Affiliation(s)
- Subha Subramanian
- Department of Neurology, Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Hanadi A Oughli
- Department of Psychiatry, Semel Institute for Neuroscience, University of California Los Angeles, Los Angeles, CA, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis; Department of Biomedical Engineering, Washington University in St. Louis, St Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, USA; Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, USA
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Altmann HM, Gebara MA, Albert SM, Morse JQ, Reynolds CF, Thomas SB, Stahl ST. Interpersonal Support Domains Associated With Symptoms of Posttraumatic Stress Among Older Black and White Adults. J Clin Psychiatry 2023; 84. [PMID: 37256634 DOI: 10.4088/jcp.22m14634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Objective: Older adults experience numerous changes in their social networks and social environment that may worsen preexisting posttraumatic stress disorder (PTSD) symptoms. This study tested whether tangible support, appraisal support, belonging support, and self-esteem were associated with trauma symptom burden among community-dwelling older Black and White adults at baseline and over 12 months of follow-up. Methods: This study used data collected from a randomized controlled trial for depression prevention in adults 50 years of age or older who had subsyndromal depression (2006-2011). Two hundred forty-four participants (including 90 older Black adults) were randomly assigned to a problem-solving therapy arm or an active control arm. The Interpersonal Support Evaluation List (ISEL) was administered at baseline and 12 months later. Linear regression analysis was used to examine associations of each of the ISEL dimensions with DSM-IV-defined PTSD symptoms at baseline and over time, with control for well-established correlates of PTSD including depression, anxiety, and sleep quality. Results: Participants were a mean (SD) of 65.6 (11.0) years of age, and 71% percent were female. Belongingness support was the only dimension of interpersonal support significantly associated with PTSD symptoms at baseline (β = -0.192, t = -3.582, P < .001) and 12 months later (β = -0.183, t = -2.735, P < .01). Regression models accounted for a large proportion of variance in PTSD symptoms. The association between belongingness support and PTSD symptoms did not vary by participant race. Conclusions: A strong perception of belongingness to family and/or friends was associated with fewer PTSD symptoms at baseline and over 12 months. This observation generates the hypothesis that behavioral interventions which directly target and modify interpersonal support may benefit both older Black and older White adults who have experienced trauma. Trial Registration: ClinicalTrials.gov identifier: NCT00326677.
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Affiliation(s)
- Helene M Altmann
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marie Anne Gebara
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer Q Morse
- Graduate Psychology Programs, Chatham University, Pittsburgh, Pennsylvania
| | - Charles F Reynolds
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stephen B Thomas
- Department of Health Policy & Management, University of Maryland, College Park, Maryland
| | - Sarah T Stahl
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Corresponding author: Sarah T. Stahl, PhD, Department of Psychiatry, University of Pittsburgh, 3811 O'Hara St, Pittsburgh, PA 15213
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Lenze E, Gebara MA, Flint A, Karp J. Turning the tide on depression in older adults: new evidence for optimal management of treatment-resistant depression. The American Journal of Geriatric Psychiatry 2023. [DOI: 10.1016/j.jagp.2022.12.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Oughli HA, Gebara MA, Ciarleglio A, Lavretsky H, Brown PJ, Flint AJ, Farber NB, Karp JF, Mulsant BH, Reynolds CF, Roose SP, Yang L, Butters MA, Lenze EJ. Intravenous Ketamine for Late-Life Treatment-Resistant Depression: A Pilot Study of Tolerability, Safety, Clinical Benefits, and Effect on Cognition. Am J Geriatr Psychiatry 2023; 31:210-221. [PMID: 36529623 PMCID: PMC10839705 DOI: 10.1016/j.jagp.2022.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 11/18/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Evidence-based treatment options for late-life treatment-resistant depression (TRD) are limited. Ketamine is a promising treatment for TRD; however, there is a paucity of data on its safety and efficacy in older adults. METHODS In this pilot clinical trial, 25 adults aged ≥60 years with TRD received IV ketamine openly twice a week for 4 weeks; partial responders at the end of this acute phase were eligible to receive weekly infusions for 4 more weeks in a continuation phase. Acceptability, tolerability, and safety, including adverse and serious adverse events (AEs and SAEs), blood pressure changes, dissociation, craving, in addition to rates of depression response and remission were evaluated. The NIH Toolbox Cognitive Battery was used to assess specific measures of executive function (EF) and overall fluid cognition. RESULTS Completion rates were 88% for the acute phase and 100% for the continuation phase. No AEs resulted in participant discontinuation, and there were no SAEs. Treatment-emergent elevation of blood pressure, dissociation, and craving were transient and did not result in any participant discontinuation. Depressive symptoms improved significantly and 48% of participants responded. During the acute phase, the EF measures and the fluid cognition composite score improved (Cohen's d = 0.61), and these improvements were sustained in the continuation phase. CONCLUSION This pilot study suggests that repeated IV ketamine infusions are well-tolerated and are associated with improvement in depression and EF in older adults with TRD. These promising findings need to be confirmed and extended in a larger randomized controlled trial.
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Affiliation(s)
- Hanadi Ajam Oughli
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA
| | - Marie Anne Gebara
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Adam Ciarleglio
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, the George Washington University, Washington, DC
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA
| | - Patrick J Brown
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, NY
| | - Alastair J Flint
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jordan F Karp
- Department of Psychiatry, College of Medicine-Tucson, University of Arizona, Tucson, AZ
| | - Benoit H Mulsant
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Centre for Addiction and Mental Health, Toronto, Canada
| | - Charles F Reynolds
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Steven P Roose
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, NY
| | - Lei Yang
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Meryl A Butters
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
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Kazan J, Lyew T, Croswell E, Buysse DJ, Gebara MA, Karp JF, Krafty RT, Rashied AA, Reynolds CF, Rollman BL, Smagula SF, Stahl ST. A digital health intervention to stabilize the 24-hour rhythm of sleep, meals, and physical activity for reducing depression among older bereaved spouses: Protocol for a randomized controlled trial. Contemp Clin Trials 2023; 124:107016. [PMID: 36414207 PMCID: PMC9839623 DOI: 10.1016/j.cct.2022.107016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite the high prevalence of depression and disruption to 24-h sleep-wake routines following the death of a spouse in late-life, no bereavement interventions have been developed to re-entrain a regular sleep-wake routine among older widow(er)s. We describe the rationale and methodology of the NIH-funded WELL Study (Widowed Elders' Lifestyle after Loss), a randomized controlled trial (RCT) comparing the efficacy of a digital health intervention (DHI) to enhanced usual care (EUC) arm for reducing depression symptoms in older spousally-bereaved adults. METHODS We will randomize approximately 200 recently bereaved (<12 months) adults aged 60+ years to one of two 12-week interventions: digital monitoring of the timing and regularity of sleep, meals, and physical activity plus weekly motivational health coaching; or enhanced usual care consisting of weekly telephone calls and similar assessment schedules. Participants will complete self-report and clinical assessments at baseline, post-intervention, and 3-, 6-, and 12-months post-intervention, and objective actigraphic assessments of their 24-h rest-activity rhythm (RAR) at baseline and 1-, 2-, and 3-months during the intervention. The primary outcome is change in depression symptoms burden (using the Hamilton Rating Scale for Depression) from pre- to post-intervention and over 12 months of follow-up. DISCUSSION WELL Study findings will inform the development of widely generalizable and scalable technology-based interventions to support bereaved spouses in community-based settings. Clinical http://Trials.gov Identifier: NCT04016896.
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Affiliation(s)
- Joseph Kazan
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thandi Lyew
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Arizona, Tucson, AZ, USA
| | - Robert T Krafty
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Ammar A Rashied
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | | | - Bruce L Rollman
- Center for Behavioral Health, Media, & Technology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah T Stahl
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA.
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10
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Altmann HM, Kazan J, Gebara MA, Blumberger DM, Karp JF, Lenze EJ, Mulsant BH, Reynolds CF, Stahl ST. Predicting Medication Nonadherence in Older Adults With Difficult-to-Treat Depression in the IRL-GRey Randomized Controlled Trial. Am J Geriatr Psychiatry 2022; 30:994-1002. [PMID: 35393165 PMCID: PMC9356982 DOI: 10.1016/j.jagp.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/31/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Nonadherence to antidepressants interferes with optimal treatment of late-life depression. This analysis examines clinical and treatment factors predicting medication nonadherence in difficult-to-treat late-life depression. METHODS Secondary analysis of data from a clinical trial of antidepressant pharmacotherapy for Major Depressive Disorder in 468 adults aged 60+ years. All participants received venlafaxine XR for 12 weeks. Nonremitters were randomized to augmentation with either aripiprazole or placebo for 12 additional weeks. Medication adherence was assessed 14 times over 24 weeks. The analyses examined sociodemographic, clinical, and treatment factors that may predict antidepressant nonadherence during early (weeks 1-6), late (weeks 7-12), and augmentation (weeks 13--24) treatment. RESULTS Poor cognitive function and early response were predictive of early nonadherence. Poor cognitive function and prior nonadherence were predictive of late nonadherence. Living alone was associated with nonadherence both late and during augmentation treatment. CONCLUSION Future studies should consider the role of early response and cognitive function to improve antidepressant adherence, particularly among older adults who live alone.
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Affiliation(s)
- Helene M Altmann
- Department of Psychiatry (HMA, JK, MAG, CFR, STS), University of Pittsburgh, Pittsburgh, PA
| | - Joseph Kazan
- Department of Psychiatry (HMA, JK, MAG, CFR, STS), University of Pittsburgh, Pittsburgh, PA
| | - Marie Anne Gebara
- Department of Psychiatry (HMA, JK, MAG, CFR, STS), University of Pittsburgh, Pittsburgh, PA
| | - Daniel M Blumberger
- Centre for Addiction and Mental Health, Department of Psychiatry (DMB, BHM), University of Toronto, Toronto, ON, Canada
| | - Jordan F Karp
- Department of Psychiatry, College of Medicine (JFK), University of Arizona, Tucson, AZ
| | - Eric J Lenze
- Department of Psychiatry (EJL), Washington University, St. Louis, MO
| | - Benoit H Mulsant
- Centre for Addiction and Mental Health, Department of Psychiatry (DMB, BHM), University of Toronto, Toronto, ON, Canada
| | - Charles F Reynolds
- Department of Psychiatry (HMA, JK, MAG, CFR, STS), University of Pittsburgh, Pittsburgh, PA
| | - Sarah T Stahl
- Department of Psychiatry (HMA, JK, MAG, CFR, STS), University of Pittsburgh, Pittsburgh, PA.
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Kazan J, Gebara MA. Geriatric considerations for collaborative care for depression in rural populations. J Am Geriatr Soc 2021; 70:85-87. [PMID: 34699058 PMCID: PMC10156449 DOI: 10.1111/jgs.17525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Joseph Kazan
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Karp JF, Kincman J, Lightfoot M, Foust JE, Maher R, Gebara MA. A systematic review of community pharmacy initiatives to improve treatment of depression and pain: Focus on types of programs and patient-reported outcomes. Res Social Adm Pharm 2021; 18:2569-2578. [PMID: 34083133 DOI: 10.1016/j.sapharm.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Depression and pain are common, disabling, mutually exacerbating conditions. Many patients living with these conditions present to community pharmacies on a regular schedule to purchase both prescribed and over-the-counter medications. Community-pharmacy based programs have been developed to improve depression and pain outcomes. METHODS The PRISMA guidelines were utilized to answer the following question: In patients with depression and/or pain, what is the effect of the existing community pharmacy programs on depression and/or pain outcomes. Queried databases included Pubmed, EMBASE, and PsychINFO. DistillerSR was used to organize the screening, abstraction, and review of data. All potential articles were evaluated by two authors, and conflicts were discussed to achieve resolution. In addition to primary outcomes, sources of potential bias and quality indicators were abstracted for every article. RESULTS Three thousand nine hundred and twenty articles were reviewed, and 13 studies met eligibility criteria (n = 7 for depression; n = 6 for pain). Most studies demonstrated improvement in measures of depression or pain. However, compared to usual care or other control conditions, most of the depression and pain-specific interventions did not provide additional symptomatic benefit. The community pharmacy-based interventions were superior for other outcomes including medication adherence, reducing stigma, improvement in self-efficacy, and improvement in general management of disease. CONCLUSION Community pharmacies may be uniquely positioned to deliver interventions that improve outcomes associated with successful depression and pain treatment outcomes. However, the benefits of published community pharmacy-based treatments for actually improving depression and pain severity has not yet been established. Innovative interventions and additional research may be needed to achieve clinical success for pharmacy interventions for depression and pain.
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Affiliation(s)
- Jordan F Karp
- University of Pittsburgh School of Medicine, Department of Psychiatry, USA; Center for Interventions to Enhance Community Health, University of Pittsburgh, USA; Department of Psychiatry, University of Arizona College of Medicine, Tucson, USA
| | - Joelle Kincman
- University of Pittsburgh School of Medicine, Department of Psychiatry, USA
| | - Michael Lightfoot
- University of Pittsburgh School of Medicine, Department of Psychiatry, USA
| | - Jill E Foust
- University of Pittsburgh Health Sciences Library System, USA
| | | | - Marie Anne Gebara
- University of Pittsburgh School of Medicine, Department of Psychiatry, USA.
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13
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Altmann H, Stahl ST, Gebara MA, Lenze EJ, Mulsant BH, Blumberger DM, Reynolds CF, Karp JF. Coprescribed Benzodiazepines in Older Adults Receiving Antidepressants for Anxiety and Depressive Disorders: Association With Treatment Outcomes. J Clin Psychiatry 2020; 81. [PMID: 32991792 DOI: 10.4088/jcp.20m13283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE There is a paucity of data on the effects of coprescribed benzodiazepines on treatment response variability and adherence to antidepressant pharmacotherapy for depression and anxiety in late life. The objective of this transdiagnostic analysis was to examine the effect of benzodiazepines on treatment outcomes in older patients with generalized anxiety disorder (GAD) or major depressive disorder (MDD). METHODS Secondary analyses of data from 2 clinical trials of antidepressant pharmacotherapy for GAD (escitalopram vs placebo, 2006-2009) or MDD (open treatment with venlafaxine, 2009-2014) were conducted. Participants included 640 adults aged 60+ years with DSM-IV-defined GAD (n = 177) or MDD (n = 463). Benzodiazepine data were collected at baseline. Adherence and treatment response were assessed over 12 weeks. The analysis addressed whether coprescribed benzodiazepines are associated with treatment response, antidepressant medication adherence, dropout, final dose of antidepressant medication, and report of antidepressant-related adverse effects. RESULTS Participants with GAD and coprescribed benzodiazepines were treated with a lower mean dosage of escitalopram and were less likely to complete the trial; there was no difference in adherence or treatment response. Participants with MDD and coprescribed benzodiazepines were less likely to tolerate a therapeutic dose of venlafaxine and reported more medication-related adverse effects; there was no difference in adherence, dropout, or treatment response. CONCLUSIONS Coprescription of benzodiazepines was associated with increased dropout in older patients with GAD and more medication-related adverse effects in older patients with MDD. However, with the systematic clinical attention offered in a clinical trial, they do not impede treatment response. Clinicians should be aware that a coprescribed benzodiazepine may be a marker of a more challenging treatment course. TRIAL REGISTRATION Data analyzed were from studies with ClinicalTrials.gov identifiers NCT00892047 and NCT00105586.
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Affiliation(s)
- Helene Altmann
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah T Stahl
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara St, Pittsburgh, PA 15213. .,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri, USA
| | - Benoit H Mulsant
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daniel M Blumberger
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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14
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Abstract
Purpose of review This narrative review seeks to ascertain the challenges older patients face with participation in mental health clinical research studies and suggests creative strategies to minimize these obstacles. Recent findings Challenges to older adults’ engagement in mental health research include practical, institutional, and collaboration-related barriers applicable to all clinical trials as well as more personal, cultural, and age-related patient barriers specific to geriatric mental health research. Universal research challenges include (1) institutional barriers of lack of funding and researchers, inter-researcher conflict, and sampling bias; (2) collaboration-related barriers involving miscommunication and clinician concerns; and (3) practical patient barriers such as scheduling issues, financial constraints, and transportation difficulties. Challenges unique to geriatric mental health research include (1) personal barriers such as no perceived need for treatment, prior negative experience, and mistrust of mental health research; (2) cultural barriers involving stigma and lack of bilingual or culturally matched staff; and (3) chronic medical issues and concerns about capacity. Summary Proposed solutions to these barriers include increased programmatic focus on and funding of geriatric psychiatry research grants, meeting with clinical staff to clarify study protocols and eligibility criteria, and offering transportation for participants. To minimize stigma and mistrust of psychiatric research, studies should devise community outreach efforts, employ culturally competent bilingual staff, and provide patient and family education about the study and general information about promoting mental health.
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Affiliation(s)
- Jordyn Newmark
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA
| | - Howard Aizenstein
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St, Bellefield Towers 726, Pittsburgh, PA 15213 USA.,Center for Interventions to Enhance Community Health, University of Pittsburgh, Pittsburgh, USA
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15
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Waterman LA, Belnap BH, Gebara MA, Huang Y, Abebe KZ, Rollman BL, Karp JF. Bypassing the blues: Insomnia in the depressed post-CABG population. Ann Clin Psychiatry 2020; 32:17-26. [PMID: 31675390 PMCID: PMC8936436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND BACKGROUND: Recovery from coronary artery bypass graft (CABG) surgery often is complicated by depression and insomnia, resulting in poorer health-related quality of life and clinical outcomes. We explored the relationships among depression, insomnia, quality of life, and the impact of a collaborative care strategy on reducing insomnia in patients after CABG surgery. METHODS METHODS: Patients with a Patient Health Questionnaire score ≥10 were randomized to nurse-delivered collaborative care for depression (n = 150) or their physician’s usual care (n = 152). A convenience sample of patients without depression (n = 151) served as the control group. Using the Hamilton Depression Rating Scale sleep questions, we created an “insomnia index.” RESULTS RESULTS: At baseline, 63% of participants who were depressed vs 12% of those who were not depressed reported insomnia. Compared with usual care, fewer collaborative care participants reported insomnia at 8 months, and they tended to have a lower insomnia score (insomnia index change score −0.95 and −1.47, respectively; P = .05) with no time-by- randomization interaction, Cohen’s d = 0.22 (95% confidence interval, −0.001 to 0.43). Participants with baseline insomnia reported greater improvements in mental health–related quality of life (Medical Outcomes Survey 36-item Short Form Mental Component Summary score; −3.32, P = .02), but insomnia was not a significant moderator of the effect of collaborative care. CONCLUSIONS CONCLUSIONS: This is the first study to examine the long-term impact on insomnia among post-CABG patients treated for depression. Future collaborative care studies could consider including a therapeutic focus for insomnia.
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Affiliation(s)
| | | | | | | | | | | | - Jordan F Karp
- Western Psychiatric Institute and Clinic, Pittsburgh, PA, 15213 USA. E-MAIL:
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16
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Gebara MA, DiNapoli EA, Lederer LG, Bramoweth AD, Germain A, Kasckow JW, Karp JF. Brief behavioral treatment for insomnia in older adults with late-life treatment-resistant depression and insomnia: a pilot study. Sleep Biol Rhythms 2019; 17:287-295. [PMID: 31632192 DOI: 10.1007/s41105-019-00211-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective Brief Behavioral Treatment for Insomnia (BBTI) is an efficacious treatment of insomnia in older adults. Behavioral treatments for insomnia can also improve depression. However, it is unknown if BBTI is feasible or has an effect in patients with insomnia and late-life treatment resistant depression (LLTRD). The aims of this study were two-fold, to test: 1) the feasibility (defined by acceptability and retention rates) of BBTI and 2) the therapeutic potency of BBTI on symptoms of insomnia and depression. Methods Eleven older Veterans with LLTRD and insomnia were recruited in a randomized control trial to receive immediate (4-weeks of BBTI followed by 3-weeks of phone call check-ins and a final in-person 8-week assessment) or delayed (3-weeks of treatment as usual [wait-list control] followed by 4-weeks of BBTI and a final in-person 8-week assessment) BBTI. The primary outcome measures included the Patient Health Questionnaire (minus the sleep item) and the Insomnia Severity Index. Results BBTI was found to be feasible in older Veterans with insomnia and LLTRD; all participants recommended BBTI and retention rates were 90.9%. There was no difference in treatment effect between the immediate BBTI and delayed BBTI groups at week 4. After both groups (immediate and delayed) received BBTI, improvements were seen in both insomnia (d = 1.06) and depression (d = 0.54) scores. Conclusions BBTI is a feasible treatment for insomnia in older adults with LLTRD. BBTI may be an effective adjunctive treatment for depression. Larger adequately-powered trials are required to confirm these preliminary findings.
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Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA; USA.,Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA; USA
| | - Elizabeth A DiNapoli
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA; USA
| | - Lisa G Lederer
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA; USA
| | - Adam D Bramoweth
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA; USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; USA
| | - Anne Germain
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA; USA
| | - John W Kasckow
- VA Beckley Healthcare System, Beckley, West Virginia; USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA; USA
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17
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Gebara MA, Siripong N, DiNapoli EA, Maree RD, Germain A, Reynolds CF, Kasckow JW, Weiss PM, Karp JF. Effect of insomnia treatments on depression: A systematic review and meta-analysis. Depress Anxiety 2018; 35:717-731. [PMID: 29782076 DOI: 10.1002/da.22776] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/06/2018] [Accepted: 04/23/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Insomnia is frequently co-morbid with depression, with a bidirectional relationship between these disorders. There is evidence that insomnia-specific interventions, such as cognitive behavioral therapy for insomnia, may lead to improvements in depression. The purpose of this systematic review and meta-analysis is to determine whether treatment of insomnia leads to improved depression outcomes in individuals with both insomnia and depression. METHODS We conduct a systematic review and meta-analysis to explore the effect of treatment for insomnia disorder on depression in patients with both disorders. RESULTS Three thousand eight hundred and fifteen studies were reviewed, and 23 studies met inclusion criteria. Although all of the studies suggested a positive clinical effect of insomnia treatment on depression outcomes, most of the results were not statistically significant. Although the interventions and populations were highly variable, the meta-analysis indicates moderate to large effect size (ES) improvement in depression as measured with the Hamilton Depression Rating Scale (ES = -1.29, 95%CI [-2.11, -0.47]) and Beck Depression Inventory (ES = -0.68, 95%CI [-1.29, -0.06]). CONCLUSIONS These results support that treating insomnia in patients with depression has a positive effect on mood. Future trials are needed to identify the subtypes of patients whose depression improves during treatment with insomnia-specific interventions, and to identify the mechanisms by which treating insomnia improves mood.
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Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Mental Illness Research, Education and Clinical Centers, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Nalyn Siripong
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth A DiNapoli
- Mental Illness Research, Education and Clinical Centers, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Rachel D Maree
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anne Germain
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Kasckow
- Mental Illness Research, Education and Clinical Centers, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Beckley VA Healthcare System, Beckley, VA, USA
| | - Patricia M Weiss
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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18
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Gebara MA, DiNapoli EA, Kasckow J, Karp JF, Blumberger DM, Lenze EJ, Mulsant BH, Reynolds CF. Specific depressive symptoms predict remission to aripiprazole augmentation in late-life treatment resistant depression. Int J Geriatr Psychiatry 2018; 33:e330-e335. [PMID: 28975710 PMCID: PMC5773368 DOI: 10.1002/gps.4813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/29/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify which specific depressive symptoms predict remission to aripiprazole augmentation in late-life treatment resistant depression. METHODS This is a secondary analysis of data from a late-life treatment resistant depression trial examining the safety and efficacy of aripiprazole augmentation. Participants aged 60 and above were randomized to aripiprazole augmentation (N = 91) versus placebo (N = 90). The main outcome was depression remission. Clinical predictors included individual Montgomery-Asberg Depression Rating Scale (MADRS) item scores categorized as symptomatic (scores >2) or nonsymptomatic (scores ≤2). RESULTS Three MADRS items predicted depression remission with aripiprazole augmentation: symptomatic scores on sleep disturbance and nonsymptomatic scores on apparent sadness and inability to feel. The 2-way and 3-way interaction terms of these MADRS items were not significant predictors of remission; therefore, the models' ability to predict remission was not improved by combining the significant MADRS items. CONCLUSIONS The identification of specific depressive symptoms, which can be clinically assessed, can be used to inform treatment decisions. Older adults with treatment resistant depression that present with sleep disturbances, lack of apparent sadness, or lack of inability to feel should be considered for aripiprazole augmentation.
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Affiliation(s)
- Marie Anne Gebara
- University of Pittsburgh School of Medicine, Pittsburgh, PA,Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Elizabeth A. DiNapoli
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - John Kasckow
- VA Beckley Healthcare System, Beckley, West Virginia
| | - Jordan F. Karp
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel M. Blumberger
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Eric J. Lenze
- Washington University School of Medicine, St. Louis, MO
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Charles F. Reynolds
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
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19
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Gebara MA, Kasckow J, Smagula SF, DiNapoli EA, Karp JF, Lenze EJ, Mulsant BH, Reynolds CF. The role of late life depressive symptoms on the trajectories of insomnia symptoms during antidepressant treatment. J Psychiatr Res 2018; 96:162-166. [PMID: 29069615 PMCID: PMC5698156 DOI: 10.1016/j.jpsychires.2017.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/13/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Sleep disturbances are common in late life depression; however, changes in insomnia symptoms during antidepressant treatment need to be characterized further. The objective of this study was two-fold: 1) to describe longitudinal trajectories of insomnia symptoms in older adults receiving antidepressant treatment and 2) to examine whether baseline depressive symptoms were associated with trajectories of sleep over time. METHODS Data was obtained from 680 older adults (aged ≥ 60) with major depression who participated in one of two protocolized open-label antidepressant treatment clinical trials (Maintenance Therapies in Late Life Depression [MTLD-3]; Incomplete Response in Late Life Depression: Getting to Remission [IRL-GRey]). Depression (total score minus sleep items) and sleep (sum of sleep items) outcomes were derived from the Hamilton Depression Rating Scale in the MLTD-3 and Montgomery-Asberg Depression Rating Scale in the IRL-GRey. RESULTS Both datasets identified 5 possible trajectories of insomnia symptoms with about half of the older adults having clinically significant baseline sleep disturbances and minimal improvement following a course of antidepressant treatment (i.e., sub-optimal sleep trajectory). Furthermore, across both datasets, worse baseline depression severity was associated with sub-optimal sleep trajectories. CONCLUSION In older adults receiving antidepressant treatment, those with clinically significant baseline sleep disturbances and greater depression severity may require adjunctive sleep-focused treatment to ameliorate sleep symptoms.
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Affiliation(s)
- Marie Anne Gebara
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - John Kasckow
- Beckley Health Care System, Behavioral Health, Beckley, WV
| | - Stephen F. Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elizabeth A. DiNapoli
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA
| | - Jordan F. Karp
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO
| | | | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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20
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DiNapoli EA, Gebara MA, Kho T, Butters MA, Gildengers AG, Albert SM, Dew MA, Erickson KI, Reynolds CF, Karp JF. Subjective-Objective Sleep Discrepancy in Older Adults With MCI and Subsyndromal Depression. J Geriatr Psychiatry Neurol 2017; 30:316-323. [PMID: 28954595 PMCID: PMC5916761 DOI: 10.1177/0891988717731827] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/OBJECTIVES We investigated the prevalence and correlates of discrepancies between self-reported sleep quality (Pittsburgh Sleep Quality Index) and objective sleep efficiency (actigraphy) in older adults with mild cognitive impairment (MCI) and subsyndromal depression. METHODS This was a secondary analysis of a clincial trial with 59 adults aged 60 years and older with MCI and subsyndromal depression. We included baseline data on participants' subjective sleep quality, objective sleep efficiency, depressive symptoms, insomnia diagnosis, and cognitive functioning. RESULTS Pittsburgh Sleep Quality Index subjective sleep quality and actigraphy-measured sleep efficiency were not significantly correlated ( r = -.06; P = .64), with 61% of participants having subjective-objective sleep discrepancies. Correlates of subjective-objective sleep discrepancy included the presence of an insomnia diagnosis and impaired memory, particularly delayed memory. CONCLUSION These findings are important because subjective underestimation of symptoms in older adults with memory impairments may result in sleep disturbances going unrecognized in clinical practice; on the other hand, an insomnia disorder may be a possible remediable contribution to subjective overestimation of sleep disturbances.
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Affiliation(s)
- Elizabeth A. DiNapoli
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marie Anne Gebara
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Terry Kho
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Meryl A. Butters
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ariel G. Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Steven M. Albert
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kirk I. Erickson
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jordan F. Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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21
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Waterman L, Stahl ST, Buysse DJ, Lenze EJ, Blumberger D, Mulsant B, Butters M, Gebara MA, Reynolds CF, Karp JF. Self-reported obstructive sleep apnea is associated with nonresponse to antidepressant pharmacotherapy in late-life depression. Depress Anxiety 2016; 33:1107-1113. [PMID: 27636232 PMCID: PMC5156576 DOI: 10.1002/da.22555] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 08/12/2016] [Accepted: 08/16/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is frequently comorbid with late-life depression. The purpose of this project was to determine, using a sample of older adults with major depressive disorder, whether patient-reported diagnosis of OSA was associated with rate of response to venlafaxine. METHODS Participants from this multisite study were adults ≥60 years old (n = 468) with major depressive disorder and a Montgomery Asberg Depression Rating Scale (MADRS) score of ≥15. Depression response was the outcome variable, defined as a MADRS score of ≤10 for two consecutive assessments at the end of 12 weeks of open-label treatment with venlafaxine 300 mg/day. To assess OSA, participants were asked if they had been diagnosed with OSA using polysomnography. RESULTS Eighty participants (17.1%) reported a diagnosis of OSA prior to baseline. Participants with OSA were more likely to be male, report greater impairment on measures of health, experience a longer duration of the index episode, and receive an adequate antidepressant trial prior to entering the study. During the 12 weeks of treatment, 40.8% responded to treatment with venlafaxine (43.6%, n = 169/388 of the no OSA group, and 27.5%, n = 22/80 of the OSA group). Participants without OSA were 1.79 times more likely to respond to treatment (HR: 1.79 [95%CI: 1.13-2.86], P < .05) compared to those with OSA. CONCLUSIONS OSA may impair response to antidepressant pharmacotherapy in depressed older adults. Future studies of antidepressant response rates among depressed older adults with OSA should both prospectively diagnose OSA and monitor adherence to treatments such as continuous positive airway pressure.
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Affiliation(s)
- Lauren Waterman
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sarah T. Stahl
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel J. Buysse
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric J. Lenze
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Benoit Mulsant
- Centre for Addiction and Mental Health, University of Toronto
| | - Meryl Butters
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marie Anne Gebara
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charles F. Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jordan F. Karp
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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22
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Conway CR, Gebara MA, Walker MC, Lessov-Schlaggar CN, Janski AM, Chibnall JT, Cristancho P, Sheline YI, Gott BM, Svrakic DM. Clinical characteristics and management of treatment-resistant depression. J Clin Psychiatry 2015; 76:1569-70. [PMID: 26646033 DOI: 10.4088/jcp.14l09462] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Gebara MA, Lenze EJ. Response to Stubbs's Letter to the Editor. Am J Geriatr Psychiatry 2015; 23:1098-9. [PMID: 26232076 DOI: 10.1016/j.jagp.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
Affiliation(s)
| | - Eric J Lenze
- University of Pittsburgh School of Medicine, Pittsburgh, PA
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Nagele P, Duma A, Kopec M, Gebara MA, Parsoei A, Walker M, Janski A, Panagopoulos VN, Cristancho P, Miller JP, Zorumski CF, Conway CR. Nitrous Oxide for Treatment-Resistant Major Depression: A Proof-of-Concept Trial. Biol Psychiatry 2015; 78:10-18. [PMID: 25577164 DOI: 10.1016/j.biopsych.2014.11.016] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/13/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND N-methyl-D-aspartate receptor antagonists, such as ketamine, have rapid antidepressant effects in patients with treatment-resistant depression (TRD). We hypothesized that nitrous oxide, an inhalational general anesthetic and N-methyl-D-aspartate receptor antagonist, may also be a rapidly acting treatment for TRD. METHODS In this blinded, placebo-controlled crossover trial, 20 patients with TRD were randomly assigned to 1-hour inhalation of 50% nitrous oxide/50% oxygen or 50% nitrogen/50% oxygen (placebo control). The primary endpoint was the change on the 21-item Hamilton Depression Rating Scale (HDRS-21) 24 hours after treatment. RESULTS Mean duration of nitrous oxide treatment was 55.6 ± 2.5 (SD) min at a median inspiratory concentration of 44% (interquartile range, 37%-45%). In two patients, nitrous oxide treatment was briefly interrupted, and the treatment was discontinued in three patients. Depressive symptoms improved significantly at 2 hours and 24 hours after receiving nitrous oxide compared with placebo (mean HDRS-21 difference at 2 hours, -4.8 points, 95% confidence interval [CI], -1.8 to -7.8 points, p = .002; at 24 hours, -5.5 points, 95% CI, -2.5 to -8.5 points, p < .001; comparison between nitrous oxide and placebo, p < .001). Four patients (20%) had treatment response (reduction ≥50% on HDRS-21) and three patients (15%) had a full remission (HDRS-21 ≤ 7 points) after nitrous oxide compared with one patient (5%) and none after placebo (odds ratio for response, 4.0, 95% CI, .45-35.79; OR for remission, 3.0, 95% CI, .31-28.8). No serious adverse events occurred; all adverse events were brief and of mild to moderate severity. CONCLUSIONS This proof-of-concept trial demonstrated that nitrous oxide has rapid and marked antidepressant effects in patients with TRD.
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Affiliation(s)
- Peter Nagele
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
| | - Andreas Duma
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael Kopec
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Marie Anne Gebara
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alireza Parsoei
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Marie Walker
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alvin Janski
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Vassilis N Panagopoulos
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Pilar Cristancho
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - J Philip Miller
- Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry; School of Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Eric J. Lenze
- Department of Psychiatry; School of Medicine; Washington University; St. Louis Missouri
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Gebara MA, Shea MLO, Lipsey KL, Teitelbaum SL, Civitelli R, Müller DJ, Reynolds CF, Mulsant BH, Lenze EJ. Depression, antidepressants, and bone health in older adults: a systematic review. J Am Geriatr Soc 2014; 62:1434-41. [PMID: 25039259 DOI: 10.1111/jgs.12945] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To examine the association between depression, antidepressant use, and bone health in older adults and the implications for treatment. DESIGN Systematic review. SETTING All studies that measured depression or antidepressant exposure and bone mineral density (BMD). PARTICIPANTS Adults aged 60 and older. MEASUREMENTS Age, site of BMD measurement using dual-energy X-ray absorptiometry (DXA), measure of depression or depressive symptoms, association between BMD changes, and depression or antidepressant use. RESULTS Nineteen observational studies met the final inclusion criteria; no experimental studies were found. Several cross-sectional and longitudinal studies found that depression or depressive symptoms were associated with a decrease in BMD. Few studies and only two longitudinal studies addressed the association between serotonin reuptake inhibitor (SRI) antidepressant use and a decrease in BMD and they had conflicting results. CONCLUSION Depression and depressive symptoms are associated with low bone mass and accelerated bone loss in older adults; putative mechanisms underlying this relationship are discussed. There is insufficient evidence that SRI antidepressants adversely affect bone health. Thus, a change in current recommendations for the use of antidepressants in older adults is not justified at the present time. Given the high public health significance of this question, more studies are required to determine whether (and in whom) antidepressants may be deleterious for bone health.
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Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry, School of Medicine, Washington University, St. Louis, Missouri
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Conway CR, Chibnall JT, Gebara MA, Price JL, Snyder AZ, Mintun MA, Craig ADB, Cornell ME, Perantie DC, Giuffra LA, Bucholz RD, Sheline YI. Association of cerebral metabolic activity changes with vagus nerve stimulation antidepressant response in treatment-resistant depression. Brain Stimul 2013; 6:788-97. [PMID: 23485649 DOI: 10.1016/j.brs.2012.11.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 10/09/2012] [Accepted: 11/25/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) has antidepressant effects in treatment resistant major depression (TRMD); these effects are poorly understood. This trial examines associations of subacute (3 months) and chronic (12 months) VNS with cerebral metabolism in TRMD. OBJECTIVE (17)Fluorodeoxyglucose positron emission tomography was used to examine associations between 12-month antidepressant VNS response and cerebral metabolic rate for glucose (CMRGlu) changes at 3 and 12 months. METHODS Thirteen TRMD patients received 12 months of VNS. Depression assessments (Hamilton Depression Rating Scale [HDRS]) and PET scans were obtained at baseline (pre-VNS) and 3/12 months. CMRGlu was assessed in eight a priori selected brain regions (bilateral anterior insular [AIC], orbitofrontal [OFC], dorsolateral prefrontal [DLPFC], and anterior cingulate cortices [ACC]). Regional CMRGlu changes over time were studied in VNS responders (decreased 12 month HDRS by ≥50%) and nonresponders. RESULTS A significant trend (decreased 3 month CMRGlu) in the right DLPFC was observed over time in VNS responders (n = 9; P = 0.006). An exploratory whole brain analysis (P(uncorrected) = 0.005) demonstrated decreased 3 month right rostral cingulate and DLPFC CMRGlu, and increased 12 month left ventral tegmental CMRGlu in responders. CONCLUSIONS/LIMITATIONS VNS response may involve gradual (months in duration) brain adaptations. Early on, this process may involve decreased right-sided DLPFC/cingulate cortical activity; longer term effects (12 months) may lead to brainstem dopaminergic activation. Study limitations included: a) a small VNS nonresponders sample (N = 4), which limited conclusions about nonresponder CMRGlu changes; b) no control group; and, c) patients maintained their psychotropic medications.
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Affiliation(s)
- Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA; Department of Neurology and Psychiatry, Saint Louis University, St. Louis, MO, USA.
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