Bipolar depression: an underestimated treatment challenge

We sought to determine whether depressive and mixed/cycling episodes were as responsive to standardized pharmacotherapeutic interventions as were manic episodes in bipolar 1 patients. As part of the Maintenance Therapies in Bipolar Disorder (MH29618, E. Frank, PI) study, forty-two acutely ill bipolar 1 patients who had been randomly assigned to one of two preliminary phase non-pharmacologic treatment strategies (interpersonal and social rhythm therapy [IPSRT] or a standard medication clinic approach) were treated according to a standardized pharmacotherapeutic protocol. Symptom severity was measured weekly with the Hamilton Depression Rating Scale and the Bech-Rafaelsen Mania Scale in order to assess symptomatic remission. Survival analysis with the proportional hazards model was performed on time to remission. Manic patients were significantly more likely to achieve clinical remission than the depressed patients (100 vs. 59%) and did so significantly more rapidly. The difference in proportion remitting and time to remission between the depressed and mixed/cycling groups was not statistically significant. No significant effect for non-pharmacologic treatment assignment was found. These results point to the need to develop more effective treatments for bipolar depression. They also suggest that psychotherapy has a limited impact in the acute phase treatment of bipolar episodes.

Psychotherapy of refractory depressions

Psychotherapy is a potentially valuable intervention for treatment-resistant depression. This review provides a brief, general overview of the use of psychotherapy to treat depression and more focused consideration of time-limited interpersonal, behavioral, and cognitive behavioral strategies for patients who are not responsive to antidepressant medication. Effective strategies emphasize individualized assessment, psychoeducation, a high level of structure and therapist activity, operationalized short-term goals, self-help and homework activities, and an empirical-collaborative approach to treatment. Although some treatment-resistant patients respond to therapy alone, more promising evidence is emerging from studies of combined strategies.

Comparison of DSM-III-R chronic major depression and major depression superimposed on dysthymia (double depression): validity of the distinction

The nosology of chronic depression has become increasingly complex since the publication of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987), but there are few data available to evaluate the validity of the distinctions between the subtypes of chronic depression. The validity of the distinction between DSM-III-R chronic major depression (CMD) and major depression superimposed on dysthymia (double depression, DD) was examined. Participants were 635 patients with chronic depression in a 12-week trial of antidepressant medications. Patients with CMD, DD, and a 3rd group with a chronic major depressive episode superimposed on dysthymia (DD/CMD) were compared on demographic and clinical characteristics, family history, and response to treatment. Few differences were evident, although the depression of patients with DD/CMD tended to be more severe.

Treatment of men with major depression: a comparison of sequential cohorts treated with either cognitive-behavioral therapy or newer generation antidepressants

OBJECTIVE

This report compares response to cognitive-behavioral therapy (CBT) and pharmacotherapy in sequential cohorts of men with DSM-III-R major depression.

METHOD

Patients were enrolled in consecutive standardized 16-week treatment protocols conducted in the same research clinic. The first group (N = 52) was treated with Beck's model of CBT, whereas the second group (N = 23) received randomized but open-label treatment with either fluoxetine (N = 10) or bupropion (N = 13). Crossover to the alternate medication was permitted after 8 weeks of treatment for antidepressant nonresponders. The patient groups were well matched prior to treatment. Outcomes included remission and nonresponse rates, as well as both independent clinical evaluations and self-reported measures of depressive symptoms.

RESULTS

Despite limited statistical power to detect differences between treatments, depressed men treated with pharmacotherapy had significantly greater improvements on 4 of 6 continuous dependent measures and a significantly lower rate of nonresponse (i.e., 13% vs. 46%). The difference favoring pharmacotherapy was late-emerging and partially explained by crossing over nonresponders to the alternate medication. The advantage of pharmacotherapy over CBT also tended to be larger among the subgroup of patients with chronic depression.

CONCLUSION

Results of prior research comparing pharmacotherapy and CBT may have been influenced by the composition of study groups, particularly the gender composition, the choice of antidepressant comparators, or an interaction of these factors. Prospective studies utilizing flexible dosing of modern antidepressants and, if necessary, sequential trials of dissimilar medications are needed to confirm these findings.

Lost human capital from early-onset chronic depression

OBJECTIVE

Chronic depression starts at an early age for many individuals and could affect their accumulation of "human capital" (i.e., education, higher amounts of which can broaden occupational choice and increase earnings potential). The authors examined the impact, by gender, of early- (before age 22) versus late-onset major depressive disorder on educational attainment. They also determined whether the efficacy and sustainability of antidepressant treatments and psychosocial outcomes vary by age at onset and quantified the impact of early- versus late-onset, as well as never-occurring, major depressive disorder on expected lifetime earnings.

METHOD

The authors used logistic and multivariate regression methods to analyze data from a three-phase, multicenter, double-blind, randomized trial that compared sertraline and imipramine treatment of 531 patients with chronic depression aged 30 years and older. These data were integrated with U.S. Census Bureau data on 1995 earnings by age, educational attainment, and gender.

RESULTS

Early-onset major depressive disorder adversely affected the educational attainment of women but not of men. No significant difference in treatment responsiveness by age at onset was observed after 12 weeks of acute treatment or, for subjects rated as having responded, after 76 weeks of maintenance treatment. A randomly selected 21-year-old woman with early-onset major depressive disorder in 1995 could expect future annual earnings that were 12%-18% lower than those of a randomly selected 21-year-old woman whose onset of major depressive disorder occurred after age 21 or not at all.

CONCLUSIONS

Early-onset major depressive disorder causes substantial human capital loss, particularly for women. Detection and effective treatment of early-onset major depressive disorder may have substantial economic benefits.

A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression

BACKGROUND

Patients with chronic forms of major depression are difficult to treat, and the relative efficacy of medications and psychotherapy is uncertain.

METHODS

We randomly assigned 681 adults with a chronic nonpsychotic major depressive disorder to 12 weeks of outpatient treatment with nefazodone (maximal dose, 600 mg per day), the cognitive behavioral-analysis system of psychotherapy (16 to 20 sessions), or both. At base line, all patients had scores of at least 20 on the 24-item Hamilton Rating Scale for Depression (indicating clinically significant depression). Remission was defined as a score of 8 or less at weeks 10 and 12. For patients who did not have remission, a satisfactory response was defined as a reduction in the score by at least 50 percent from base line and a score of 15 or less. Raters were unaware of the patients' treatment assignments.

RESULTS

Of the 681 patients, 662 attended at least one treatment session and were included in the analysis of response. The overall rate of response (both remission and satisfactory response) was 48 percent in both the nefazodone group and in the psychotherapy group, as compared with 73 percent in the combined-treatment group. (P<0.001 for both comparisons). Among the 519 subjects who completed the study, the rates of response were 55 percent in the nefazodone group and 52 percent in the psychotherapy group, as compared with 85 percent in the combined-treatment group (P<0.001 for both comparisons). The rates of withdrawal were similar in the three groups. Adverse events in the nefazodone group were consistent with the known side effects of the drug (e.g., headache, somnolence, dry mouth, nausea, and dizziness).

CONCLUSIONS

Although about half of patients with chronic forms of major depression have a response to short-term treatment with either nefazodone or a cognitive behavioral-analysis system of psychotherapy, the combination of the two is significantly more efficacious than either treatment alone.

Treatment of severe depression

A significant minority of depressed outpatients and a vast majority of those hospitalized for depression can be considered severely ill. Severe depressive states are quite heterogeneous and include the more classical subforms (e.g., melancholia or psychotic depression) as well as various comorbid presentations. This article reviews the classification, phenomenology, pathophysiology, and treatment of severe depression.

Fluoxetine versus placebo in depressed alcoholics: a 1-year follow-up study

The authors conducted a first study to evaluate the long-term efficacy of fluoxetine for decreasing the depressive symptoms and the drinking of patients with comorbid major depressive disorder and alcohol dependence. This study consisted of a 1-year naturalistic follow-up of 31 patients who previously had completed a 3-month double-blind, placebo-controlled study of fluoxetine in depressed alcoholics. The fluoxetine group continued to demonstrate less depressive symptoms and less drinking than the placebo group at the 1-year follow-up evaluation. The results of the 1-year follow-up evaluation suggest persistent efficacy for fluoxetine for treating the depressive symptoms and the drinking of depressed alcoholics.

Adjunctive psychotherapy for bipolar disorder: effects of changing treatment modality

In a randomized, controlled trial, the authors studied an adjunctive, individual psychotherapy, interpersonal and social rhythm therapy (IPSRT) for bipolar disorder. After stabilizing participants with episode appropriate pharmacotherapy and either IPSRT or intensive clinical management (CM), participants were reassigned to IPSRT or CM in conjunction with pharmacotherapy for 2 years of preventative treatment. Early results (n = 82) suggest that altering participants' treatment assignment at entry to the preventative phase is related to risk of recurrence. Participants remaining in the same treatment for both acute and preventative phases had lower rates of recurrence (< 20% vs. > 40%) and levels of symptomatology over the subsequent 52 weeks than those reassigned to the alternate modality. This finding, consistent with the authors' philosophy that bipolar patients benefit from stable routines, suggests that disruptions in the psychosocial treatment plan contribute to worse outcomes.

Is cognitive behavior therapy just a 'nonspecific' intervention for depression? A retrospective comparison of consecutive cohorts treated with cognitive behavior therapy or supportive counseling and pill placebo

BACKGROUND

There is a dearth of placebo-controlled studies of cognitive behavior therapy (CBT) of depression and the largest such study, by Elkin et al. (Arch. Gen. Psychiatry 46 (1989) 971-982), failed to find a significant difference between CBT and a clinical management plus placebo condition.

METHODS

The outcomes of two consecutive cohorts of out-patients with major depressive disorder, treated with either CBT (n=90) or a nonspecific control condition (support-counseling-placebo; SCP: n=100), were compared. Although the principal comparisons between the CBT and SCP conditions were delimited to the first 4 weeks of treatment, a secondary set of analyses addressed the subset of 16 patients who received 12 additional weeks of supportive therapy.

RESULTS

A consistent pattern of statistically and clinically significant differences favoring CBT over SCP was found in both weeks 4 and 16.

LIMITATIONS

Interpretation of these findings are subject to several potential confounds, including the non-randomized nature of the groups and the greater amount of therapeutic contact during the first 4 weeks of CBT.

CONCLUSIONS

While these results do not lessen the need for additional prospective studies, our findings do suggest that CBT has therapeutic effects beyond those attributable to placebo-expectancy and other nonspecific factors.

Acute efficacy of ECT in the treatment of major depression in the old-old

OBJECTIVE

There are few data addressing the outcome of ECT for persons over 75 years of age. In a prospective, multisite study, the authors compared characteristics and treatment outcomes of adult (59 and younger), young-old (60 to 74 years), and old-old (75 and older) patients treated with ECT for major depression.

METHOD

At four hospitals, 268 patients with primary unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale were treated with suprathreshold right unilateral or bilateral ECT in a standardized manner. Demographic variables, clinical characteristics, and short-term outcomes of the three groups were compared.

RESULTS

The demographic and clinical characteristics of the old-old patients were similar to those of the young-old patients, whereas both groups differed from the adult patients on these variables. Both older groups had significantly greater burdens from physical illness and global cognitive impairment at baseline than the adult subjects. Both older groups had shorter index depressive episodes and were less likely to have had inadequate responses to adequate medication trials before ECT. The older groups had higher seizure thresholds, but the three groups received similar courses of treatment. The adult patients experienced a significantly lower rate of ECT response (54%) than the young-old patients (73%), while the old-old patients had an intermediate rate of response (67%).

CONCLUSIONS

Despite a higher level of physical illness and cognitive impairment, even the oldest patients with severe major depression tolerate ECT in a manner similar to that for younger patients and demonstrate similar or better acute response.

Adjunctive psychotherapy for bipolar disorder: effects of changing treatment modality

In a randomized, controlled trial, the authors studied an adjunctive, individual psychotherapy, interpersonal and social rhythm therapy (IPSRT) for bipolar disorder. After stabilizing participants with episode appropriate pharmacotherapy and either IPSRT or intensive clinical management (CM), participants were reassigned to IPSRT or CM in conjunction with pharmacotherapy for 2 years of preventative treatment. Early results (n = 82) suggest that altering participants' treatment assignment at entry to the preventative phase is related to risk of recurrence. Participants remaining in the same treatment for both acute and preventative phases had lower rates of recurrence (< 20% vs. > 40%) and levels of symptomatology over the subsequent 52 weeks than those reassigned to the alternate modality. This finding, consistent with the authors' philosophy that bipolar patients benefit from stable routines, suggests that disruptions in the psychosocial treatment plan contribute to worse outcomes.

Age of onset in chronic major depression: relation to demographic and clinical variables, family history, and treatment response

BACKGROUND

The clinical and etiological significance of the early-late onset distinction in chronic major depressive disorder was explored.

METHOD

Subjects were 289 outpatients with DSM-III-R chronic major depression drawn from a multi-site study comparing the efficacy of sertraline and imipramine in the acute and long-term treatment of chronic depression. Patients received comprehensive evaluations using semi-structured interviews and rating scales.

RESULTS

Early-onset chronic major depression was associated with a longer index major depressive episode and higher rates of recurrent major depressive episodes, comorbid personality disorders, lifetime substance use disorders, depressive personality traits, and a history of psychiatric hospitalization. In addition, more early-onset patients tended to have a family history of mood disorders. The early-late onset distinction was not associated with differences in symptom severity, functional impairment, or treatment response.

LIMITATIONS

Family members were not interviewed directly; there were a large number of statistical comparisons; and interrater reliability of the assessments was not evaluated.

CONCLUSIONS

Early-onset chronic major depression has a more malignant course and is associated with greater comorbidity than late-onset chronic major depression.

Anger attacks: correlates and significance of an underrecognized symptom

BACKGROUND

Anger attacks over provocations described as trivial by the individual are an underrecognized symptom associated with aggressive acts. They are usually followed by guilt and regret. Anger attacks among mothers are an important problem because they are often directed at the woman's spouse and/or children. This study examines the prevalence and correlates of anger attacks in a psychiatric clinic for women who are either pregnant or up to 18 months postpartum.

METHOD

Fifty consecutive consenting patients were assessed at initial presentation with the Structured Clinical Interview for DSM-IV Axis I Disorders, a modified Anger Attacks Questionnaire, self-reports of psychiatric symptoms and psychosocial variables, and clinician ratings.

RESULTS

Thirty (60%) of 50 patients reported anger attacks. Of those with anger attacks, 76.7% worried about them, and 73.3% had tried to prevent them. Compared with women without anger attacks, those with anger attacks were significantly more likely to report higher state and trait anger (p < .001), have a diagnosis of unipolar depression (p < .01), report more aggression directed at immediate family, and avoid their children. Both groups displayed little angry affect in the interview, thus appearing similar at assessment.

CONCLUSION

Anger attacks in response to children and spouse were common in this group of women and were associated with subjective distress. Because those with and without anger attacks appear similar at interview, inquiring about the presence of anger attacks is important to ensure that they become a focus of treatment.

Pursuit tracking impairments in schizophrenia and mood disorders: step-ramp studies with unmedicated patients

BACKGROUND

Eye tracking abnormalities are highly prevalent in schizophrenia, and are among the most promising phenotypic familial markers for the disorder. The neurophysiologic mechanisms underlying these disturbances and their diagnostic specificity for schizophrenia are not yet well characterized.

METHODS

This study assessed eye tracking deficits using foveopetal and foveofugal step-ramp tasks (ramps moving toward and away from central fixation after an initial step respectively) across a range of target velocities in anti-psychotic-naive schizophrenia patients, previously treated but currently unmedicated chronic schizophrenia patients, unmedicated patients with either bipolar or unipolar mood disorders, and healthy volunteers.

RESULTS

All patient groups demonstrated reduced pursuit gain in open loop and closed loop visual tracking conditions. There were no significant group differences in the latency or accuracy of catch-up saccades on foveofugal ramp tasks.

CONCLUSIONS

These findings indicate that open and closed loop pursuit eye movements are impaired during acute episodes of schizophrenia and mood disorders. The intact accuracy of saccades to moving targets in all patient groups indicates that an adequate representation of motion information is available to the saccade system. Therefore, pursuit disturbances in mood disorders and schizophrenia seem to result, at least in part, from a disturbance in sensorimotor integration in the pursuit system after the initial extraction of sensory motion information. No eye movement abnormalities observed during performance of step ramp tasks were specific to schizophrenia.

Antidepressant treatment of the depressed patient with insomnia

Sleep disturbances are an integral part of depressive disorder. As such, they are a part of all contemporary sets of diagnostic criteria for major depression and of all major symptom-based rating scales for depression. Insomnia is a particularly frequent complaint, and it is reported by more than 90% of depressed patients. Although the "kindling" or "illness transduction" model of depression remains hypothetical, there is evidence that people with recurrent depression have more pronounced abnormalities of sleep neurophysiology than those experiencing a single or initial episode. Therefore, early relief of insomnia in a depressed patient, in addition to alleviating other symptoms, may increase adherence to treatment and increase daytime performance and overall functioning, while complete relief of insomnia may improve prognosis. Stimulation of serotonin-2 (5-HT2) receptors is thought to underlie insomnia and changes in sleep architecture seen with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This is the reason why hypnotics or low-dose trazodone are commonly coprescribed at the initiation of the treatment with either the SSRIs or SNRIs. On the other hand, antidepressant drugs with 5-HT2 blocking properties, such as mirtazapine or nefazodone, alleviate insomnia and improve sleep architecture. In depressed patients, mirtazapine produces a significant shortening of sleep-onset latency, increases a total sleep time, and leads to a marked improvement in sleep efficiency. Antidepressants with preferential 5-HT2 blocking properties are therefore a good treatment option for depressed patients with marked insomnia.

Long-term nature of depression

Many, if not most, people with depression are at high risk to develop a recurrent and potentially chronic disorder, characterized by deleterious effects on vocational, social, and family functioning. Recent evidence also suggests that recurrent episodes of severe depression are associated with changes in brain function that further heighten vulnerability and functional impairment. The best way to deal with these sobering problems is prevention via vigorous treatment of the index episode (to produce complete remission) and more routine use of longer term models of prophylactic therapy. After briefly reviewing the relevant data on epidemiology and natural history, this article focuses on the 4 "arms" of preventative treatment: psychoeducation, pharmacotherapy, adherence, and psychotherapy. Like the modern approach to treatment of hypertension, a conscientious and integrated approach to preventative therapy saves lives and has profoundly beneficial effects for our patients, their loved ones, and society.

Gender-specific response to depression treatment

Gender-specific responses to pharmacotherapy or psychotherapy for depression are virtually unknown. Early studies rarely examined treatment response by gender, and the small number of males studied has led to inaccurate comparisons between male and female response. This article addresses conceptual issues and reviews what little can be ascertained from earlier studies of the relationship between gender and treatment outcome. It also presents data from a series of studies conducted over the last 15 years at the University of Pittsburgh School of Medicine.

Is psychotherapy an effective treatment for melancholia and other severe depressive states?

The treatment of severe depression with psychotherapy, alone, is controversial. In this paper, we review the historical, conceptual, and empirical contexts of this controversy. In addition to work by others, we review recent work from our institute which has examined the psychobiological substrates of response to treatment in depressive subtypes. We examine the traditional categories that describe severe depressions. The features and psychobiological correlates of melancholia are discussed, as is the relationship between melancholia and aging. Research on treatment of melancholia and other severe depressive states with psychotherapies such as cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) is reviewed in detail. We conclude that although some melancholic patients are responsive to IPT or CBT, there is not yet compelling evidence that melancholic patients respond to psychotherapy as well as they do to medications. The potentially mediating effects of hypercortisolism, alterations of sleep neurophysiology, and disturbances of information processing and regional cerebral metabolism represent fertile grounds for future investigation. We discuss the practical implications of the literature reviewed.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

BACKGROUND

This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients.

METHODS

Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month.

RESULTS

Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed.

CONCLUSION

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Redefining antidepressant efficacy toward long-term recovery

Most studies of antidepressant therapy assess short-term or acute phase efficacy and tolerability. However, 30% to 50% of patients with major depression will experience a relapse during the 4 to 6 months following treatment of a depressive episode. Patients who do not remit fully during the acute phase of therapy are at particularly high risk for relapse. In addition, 75% to 80% of patients will experience recurrent depression during their lifetime. Thus, full remission and long-term recovery, rather than short-term response, are the desired outcomes from antidepressant treatment. There is a need for prospective, long-term studies to investigate the response and recovery to antidepressant therapy. Research conducted by our group at the University of Pittsburgh has demonstrated that the rate of recurrence can be significantly reduced across 3 to 5 years of continuous treatment with imipramine. Although relatively little research on longer term, preventative pharmacotherapy has been conducted, studies with newer agents including selective serotonin reuptake inhibitors (SSRIs), nefazodone, and mirtazapine also indicate a lower relapse rate with active drug compared with placebo. The long-term efficacy of venlafaxine has been demonstrated in both an extension study and a recent prospective, double-blind discontinuation study. There is increasing evidence that antidepressants, including the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine, are well tolerated and effective options for longer term therapy.

Prefrontal cortical dysfunction in depression determined by Wisconsin Card Sorting Test performance

OBJECTIVE

Neuroimaging studies have demonstrated reduced prefrontal cortical blood flow and metabolism in depression, but the neurobehavioral significance of these observations is not yet established.

METHOD

The Wisconsin Card Sorting Test, a widely used neuropsychological index of prefrontal cortical function, was administered to 79 patients with major depression who had been unmedicated for at least 28 days, to 47 patients with schizophrenia who had never received antipsychotic medication, and to 61 healthy comparison subjects.

RESULTS

Depressed patients demonstrated significant deficits on multiple Wisconsin Card Sorting Test measures compared with healthy individuals. These deficits were correlated with the severity of depression and were less severe than those demonstrated by patients with schizophrenia.

CONCLUSIONS

These results provide neuropsychological evidence for significant prefrontal cortical dysfunction in depression.

Natural history and preventative treatment of recurrent mood disorders

This chapter focuses on recent developments in our understanding of the etiology, epidemiology, and treatment of recurrent mood disorders. It addresses the changing relationship between endogenous and exogenous factors over time in the etiology of mood episodes. In the area of epidemiology, the chapter presents new information on the prevalence of various subtypes and male/female differences in lifetime risk. Complications of the mood disorders, such as suicide, and important comorbidities, including alcoholism and substance abuse, are discussed. In the area of treatment, the life-long nature of many of the mood disorders is described, as is the consequent role of the primary care physician in their management. The evidence for the efficacy of the depression-specific psychotherapies, cognitive therapy and interpersonal therapy, is reviewed. Current issues in the pharmacotherapy of mood disorders are discussed, including the relative efficacy of the older antidepressants versus the newer selective serotonin reuptake inhibitors (SSRIs) and the treatment of various subtypes of mood disorders, including dysthymia, chronic depression, and atypical depression. Finally, the chapter describes recent advances in the treatment of bipolar disorder.