Psychotherapy employed additionally to Psychopharmacotherapy is not related to Better Treatment Outcome in Major Depressive Disorder

Introduction

Although numerous effective antidepressant (AD) strategies are available for the treatment of major depressive disorder (MDD), many patients do not achieve satisfactory treatment response.

Objectives

The aims of the present European, cross-sectional, multicenter, naturalistic study were (1) to determine the proportion of patients suffering from primary MDD who received additional psychotherapy to their ongoing psychopharmacotherapy and (2) to identify the associated socio-demographic and clinical patterns.

Methods

Patients receiving both treatments were compared to those lacking concomitant additional psychotherapy that was manual-driven psychotherapy (MDP) in all cases.

Results

While 68.8% of a total of 1279 MDD patients received exclusively psychopharmacotherapy, 31.2% underwent a psychopharmacotherapy-MDP combination. The latter patient population was rather younger, higher educated, employed, exhibited an earlier mean age of MDD onset, lower severity of current depressive symptoms with lower odds of suicidality and higher rates of melancholic features, and comorbid asthma and migraine, and was generally treated with lower daily doses of their first-line ADs. Whereas agomelatine was more commonly dispensed in these patients, selective serotonin reuptake inhibitors were more often prescribed in MDD patients lacking additional MDP. No significant between-group differences were detected in terms of treatment outcome.

Conclusions

The fact that the employment of additional MDP was not related to better treatment outcome in MDD represents our major and clinically most relevant finding. Generally, MDP was employed in a minority of our patients who experienced rather beneficial socio-demographic and clinical characteristics. This might reflect an inferior accessibility of these psychotherapeutic techniques for patients who are more severely ill and less socio-economically privileged.

Disclosure

References Bartova L, Fugger G, Dold M, Swoboda MMM, Zohar J, Mendlewicz J, Souery D, Montgomery S, Fabbri C, Serretti A, Kasper S. Combining psychopharmacotherapy and psychotherapy is not associated with better treatment outcome in major depressive disor

Clinical factors predicting treatment resistant depression: affirmative results from the European multicenter study

OBJECTIVES

Clinical variables were investigated in the 'treatment resistant depression (TRD)- III' sample to replicate earlier findings by the European research consortium 'Group for the Study of Resistant Depression' (GSRD) and enable cross-sample prediction of treatment outcome in TRD.

EXPERIMENTAL PROCEDURES

TRD was defined by a Montgomery and Åsberg Depression Rating Scale (MADRS) score ≥22 after at least two antidepressive trials. Response was defined by a decline in MADRS score by ≥50% and below a threshold of 22. Logistic regression was applied to replicate predictors for TRD among 16 clinical variables in 916 patients. Elastic net regression was applied for prediction of treatment outcome.

RESULTS

Symptom severity (odds ratio (OR) = 3.31), psychotic symptoms (OR = 2.52), suicidal risk (OR = 1.74), generalized anxiety disorder (OR = 1.68), inpatient status (OR = 1.65), higher number of antidepressants administered previously (OR = 1.23), and lifetime depressive episodes (OR = 1.15) as well as longer duration of the current episode (OR = 1.022) increased the risk of TRD. Prediction of TRD reached an accuracy of 0.86 in the independent validation set, TRD-I.

CONCLUSION

Symptom severity, suicidal risk, higher number of lifetime depressive episodes, and comorbid anxiety disorder were replicated as the most prominent risk factors for TRD. Significant predictors in TRD-III enabled robust prediction of treatment outcome in TRD-I.

International Union of Basic and Clinical Pharmacology CIV: The Neurobiology of Treatment-resistant Depression: From Antidepressant Classifications to Novel Pharmacological Targets

Major depressive disorder is one of the most prevalent and life-threatening forms of mental illnesses and a major cause of morbidity worldwide. Currently available antidepressants are effective for most patients, although around 30% are considered treatment resistant (TRD), a condition that is associated with a significant impairment of cognitive function and poor quality of life. In this respect, the identification of the molecular mechanisms contributing to TRD represents an essential step for the design of novel and more efficacious drugs able to modify the clinical course of this disorder and increase remission rates in clinical practice. New insights into the neurobiology of TRD have shed light on the role of a number of different mechanisms, including the glutamatergic system, immune/inflammatory systems, neurotrophin function, and epigenetics. Advances in drug discovery processes in TRD have also influenced the classification of antidepressant drugs and novel classifications are available, such as the neuroscience-based nomenclature that can incorporate such advances in drug development for TRD. This review aims to provide an up-to-date description of key mechanisms in TRD and describe current therapeutic strategies for TRD before examining novel approaches that may ultimately address important neurobiological mechanisms not targeted by currently available antidepressants. All in all, we suggest that drug targeting different neurobiological systems should be able to restore normal function but must also promote resilience to reduce the long-term vulnerability to recurrent depressive episodes.

Clinical correlates of augmentation/combination treatment strategies in major depressive disorder

OBJECTIVE

This multicenter, multinational, cross-sectional study aimed to investigate clinical characteristics and treatment outcomes associated with augmentation/combination treatment strategies in major depressive disorder (MDD).

METHOD

Sociodemographic, clinical, and treatment features of 1410 adult MDD patients were compared between MDD patients treated with monotherapy and augmentation/combination medication using descriptive statistics, analyses of covariance (ancova), and Spearman's correlation analyses.

RESULTS

60.64% of all participants received augmentation and/or combination strategies with a mean number of 2.18 ± 1.22 simultaneously prescribed psychiatric drugs. We found male gender, older age, Caucasian descent, higher weight, low educational status, absence of occupation, psychotic symptoms, melancholic and atypical features, suicide risk, in-patient treatment, longer duration of hospitalization, some psychiatric comorbidities (panic disorder, agoraphobia, obsessive-compulsive disorder, and bulimia nervosa), comorbid somatic comorbidity in general and concurrent hypertension, thyroid dysfunction, diabetes, and heart disease in particular, higher current and retrospective Montgomery and Åsberg Depression Rating Scale total scores, treatment resistance, and higher antidepressant dosing to be significantly associated with augmentation/combination treatment. These findings were corroborated when examining the number of concurrently administered psychiatric drugs in the statistical analyses.

CONCLUSION

Our findings suggest a clear association between augmentation/combination strategies and treatment-resistant/difficult-to-treat MDD conditions characterized by severe symptomatology and high amount of psychiatric and somatic comorbidities.

Prescribing patterns of psychiatric drugs in major depressive disorder – Findings from a large European multicenter, cross-sectional study

Introduction

The multicenter, cross-sectional survey summarizes the current prescription patterns of psychopharmacological medications in patients with major depressive disorder (MDD) treated in European university psychiatric centers.

Methods

The study included a total of 1181 MDD patients who were recruited in 9 academic sites across 8 European countries. Socio-demographic, clinical, and psychopharmacological characteristics were collected within a detailed clinical interview and the current depressive symptom severity was measured by the Montgomery and Åsberg Depression Rating Scale (MADRS). Symptom reduction during the present MDD episode was analyzed by calculating retrospective MADRS scores. Descriptive statistics, analyses of variance (ANOVAs), and Spearman correlation analyses were performed to examine the impact of various features on the applied pharmacological strategies.

Results

Regarding first-line antidepressant medication, the most frequently prescribed drug classes were selective serotonin reuptake inhibitors (SSRIs) (53.4%), serotonin-norepinephrine reuptake inhibitors (SNRIs) (23.6%), noradrenergic and specific serotonergic antidepressants (NaSSAs) (8.2%), tricyclic antidepressants (TCA) (5.1%), and the melatonergic antidepressant agomelatine (5.0%). The most commonly used individual antidepressants were escitalopram (18.4%), venlafaxine (15.2%), sertraline (12.9%), paroxetine (9.1%), mirtazapine (8.2%), duloxetine (7.0%), and fluoxetine (6.5%). Among the patients, 59.4% were treated with polypsychopharmaceutical medications (mean: 2 drugs) and for the number of individual drugs, we found a significant correlation with the present MADRS total score and the MADRS total score change during the current depressive episode.

Conclusion

Consistent with surveys investigating primarily municipal psychiatric treatment centers, we could replicate the observation that SSRIs are the most commonly used antidepressants in MDD for the first time for European university centers.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Systematic evaluation of dose-escalation strategies after initial non-response to standard-dose pharmacotherapy in schizophrenia

Objectives

This meta-analysis investigates if dose increase of an antipsychotic drug (high-dose treatment, dose escalation) is advantageous for schizophrenic patients who failed to respond adequately to standard-dose treatment with the same antipsychotic.

Methods

Within a systematic literature survey, we identified all randomized controlled trials (RCTs) comparing a dose increase directly to standard-dose continuation treatment in schizophrenic subjects with initial non-response to prospective standard-dose pharmacotherapy with the same antipsychotic. The primary outcome was mean change in the Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcomes were dichotomous response and attrition rates. Study selection and data extraction were conducted independently by two authors. We calculated effect sizes (Hedges's g and risks ratios) using the Mante–Haenszel random-effects model. Meta-regression analyses were performed to explore the influence of the degree of the dose increase on effect sizes.

Results

Five trials (n = 348) examining quetiapine (n = 2, n = 191), ziprasidone (n = 1, n = 75), haloperidol (n = 1, n = 48), and fluphenazine (n = 1, n = 34) were included. We found no significant between-group differences for the mean PANSS/BPRS total score change, even not when itemized according to the individual antipsychotic agents. There were no between-group differences for response and dropout rates. The non-significant meta-regressions indicate no impact of the different amounts of dose increments on effect sizes.

Conclusions

We found no evidence for the efficacy of a dose escalation after initial non-response to standard-dose pharmacotherapy as general advisable treatment strategy. As the high-dose treatment was not accompanied by significant increased attrition rates, appropriate tolerability and acceptability of this pharmacological option can be assumed.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

P02 - 369 - Neuroimaging of the various symptom dimensions in obsessive - compulsive disorder - a systematic review

Introduction

Several neuroimaging studies in obsessive-compulsive disorders (OCD) have shown a dysfunction in the orbito-fronto-striato-thalamamic neural circuitry as the fundamental neuropathological correlate, consistent across all symptom subtypes.

Therefore, the neurobiological differentiation of the various obsessive-compulsive symptoms is attracting increasing interest in neuroimaging as this clinical picture becomes increasingly subclassified.

Method

A systematic literature survey was used to search for original papers that studied the neurobiological correlates of the various symptom dimensions of OCD (symmetry, forbidden thoughts, washing, hoarding).

Results

It was possible to include a total of 15 original papers in the assessment. The “forbidden thoughts” factor, which also includes compulsion to control, is associated mainly with activations in brain structures of the cognitive control system, i.e. the basal ganglia and parts of the anterior cingulate cortex (ACC). Therefore, the neural representation pattern of “forbidden thoughts” differs clearly from that of “washing”, in which cerebral regions of emotional control seem to be particularly involved, i.e. the orbito-frontal cortex (OFC), ACC, the amygdala and insula. On the other hand, the “hoarding and collecting” dimension is primarily associated with brain areas involved in decision-making, i.e. the ventro-medial OFC, the dorsal ACC and the dorso-lateral prefrontal cortex (DLPC).

Discussion

The results confirm the hypothesis that all dimensions of OCD are based on different neuronal networks, which underlines the neurobiological heterogeneity of the clinical picture of OCD, thus pointing the way for future research strategies.

Does a high degree of instability during psychotherapy enhance a positive therapy-response? - an evaluation of an in-patient behavior therapy of obsessive-compulsive disorder

Introduction

The study evaluates a central hypothesis of synergetic psychotherapy research according to which a marked instability in the psychotherapeutic process is associated with high response rates.

Methods

14 patients with obsessive-compulsive disorder (OCD) successfully completed an eight-week in-patient course of multi-modal behavior therapy with exposure exercises followed by response management. The instability during the course of the therapy was recorded by daily self-assessment by the patient using the Synergetic Navigation System (SNS), an Internet-based real-time monitoring procedure.

Results

There was a negative correlation between the degree of the instability and the percentage reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (r = −0.395; P = 0.199), the “Global Severity Index” (GSI) of the symptom check-list (SCL-90-R) (r = −0.718; P = 0.013), the scale value for obsessive-compulsiveness in the SCL-90-R (r = −0.782; P = 0.004) and the remaining sub-scales of this data-gathering instrument.

Conclusions

An unstable progress of the psychotherapy causes a smaller reduction in symptoms than a stable one. The contradiction relative to the study hypothesis is possibly based on the special features of OCD, with a high level of patient insecurity when anticipating new, non-obsessive-compulsive ways of thought and behavior. The relationships between instability and reduction in symptoms appear to be diagnosis-specific.

Antipsychotics in obsessive-compulsive disorder - an auspicious approach for treatment-resistant patients?

Introduction

Because only 40 – 60% of all patients with obsessive-compulsive disorder (OCD) respond to selective serotonin reuptake inhibitors (SSRIs), the evaluation of alternative therapy methods in the presence of treatment resistance has high clinical relevance. In this context, many studies have examined additive medication with antipsychotics.

Method

All double-blind randomised controlled trials (DBRCTs) that evaluated the efficacy of a combination therapy of antipsychotics and SSRIs in treatment-resistant OCD were covered by systematic literature searches.

Results

A total of ten DBRCTs were identified (four for quetiapine, three for risperidone, two for olanzapine and one for haloperidol) with a participant collective comprising in total 316 treatment-resistant OCD patients. After the augmentation therapy, significantly more subjects in the intervention group (antipsychotic + SSRI), 32% of the patients, fulfilled the response criterion (reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ≥ 35%) than in the control group (placebo + SSRI) (relative risk (RR) = 2.08; 95% CI: 1.3 – 3.32). The standardised mean difference (SMD) of the Y-BOCS reduction between the pooled two study-groups revealed an effect size of 0,62. The sub-group analyses showed significant efficacy only for haloperidol and risperidone. Further significant differences existed regarding the duration of SSRI medication before the augmentation phase.

Conclusion / Discussion

Based on the favourable benefit-risk-ratio, risperidone can be regarded as the agent of first choice for augmentation treatment with an SSRI. Overall, about one third of patients benefit from this therapy option. However, further scientific studies are needed before sufficiently empirically secured pharmacological treatment recommendations can be expressed.