Antidepressants for depression in physically ill people

[Spectral model of therapy resistant depression]

In the present article, we describe different staging models of therapy resistant depression (TRD). Their advantages and disadvantages are pointed out. Also the possibilities of using various TRD staging models in clinical practice are considered. It is proposed to develop a single spectral model of TRD.

Comorbidity of depression with physical disorders: research and clinical implications

Depression is prevalent in patients with physical disorders, particularly in those with severe disorders such as cancer, stroke, and acute coronary syndrome. Depression has an adverse impact on the courses of these diseases that includes poor quality of life, more functional impairments, and a higher mortality rate. Patients with physical disorders are at higher risk of depression. This is particularly true for patients with genetic and epigenetic predictors, environmental vulnerabilities such as past depression, higher disability, and stressful life events. Such patients should be monitored closely. To appropriately manage depression in these patients, comprehensive and integrative care that includes antidepressant treatment (with considerations for adverse effects and drug interactions), treatment of the physical disorder, and collaborative care that consists of disease education, cognitive reframing, and modification of coping style should be provided. The objective of the present review was to present and summarize the prevalence, risk factors, clinical correlates, current pathophysiological aspects including genetics, and treatments for depression comorbid with physical disorders. In particular, we tried to focus on severe physical disorders with high mortality rates, such as cancer, stroke, and acute coronary syndrome, which are highly comorbid with depression. This review will enhance our current understanding of the association between depression and serious medical conditions, which will allow clinicians to develop more advanced and personalized treatment options for these patients in routine clinical practice.

Sick and tired: mood, fatigue, and inflammation in cancer

Cancer patients commonly experience depression and fatigue before, during, and after treatment. Symptoms can be debilitating, and the risks associated with unrecognized or inadequately treated depression are substantial. Inflammation may be important in the genesis of depression and fatigue in cancer patients; potential neurobiological mechanisms of inflammation-related behavioral symptoms are reviewed. Randomized studies of pharmacologic treatments for depression in cancer populations are limited, but available data are generally encouraging. Studies of pharmacologic treatments for cancer-related fatigue have been more numerous but with mixed results. A practical approach to pharmacologic treatment of depression and fatigue in cancer patients involves weighing the potential risks and benefits of specific agents, including potential for adverse or advantageous side effects. Progress in understanding the neurobiological mechanisms underlying inflammation-related behavioral symptoms will provide opportunities for the development of novel and targeted treatments.

Palliative and supportive care for glioma patients

The diagnosis of a brain tumor is a life-changing event for patients and families. High-grade gliomas are incurable and long-term survival remains limited. While low-grade glioma patients have better outcomes, their quality of life is often affected by a variety of symptoms as well. Helping glioma patients improve quality of life at all stages of illness is an important goal for the interdisciplinary care team. There is evidence from advanced lung cancer patients that early involvement of a palliative care team can improve patient's quality of life, symptom burden, and even survival and a similar approach benefits glioma patients as well. Patients with high-grade and low-grade glioma often suffer from significant symptom burden. We discuss how validated global symptom assessments and symptom-specific screening tools are useful to identify distressing symptoms. Seizures, fatigue, depression, and anxiety are some of the more common symptoms throughout the disease course and should be managed actively. Patients with glioma also have high symptom burden at the end of life and the majority lose decision-making capacity. Advance care planning conversations early in the disease course are essential to elicit the patient's wishes for end of life care and effective communication with surrogate decision makers during all stages of the disease helps ensure that those wishes are respected.

Putting evidence into practice: evidence-based interventions for depression

Depression is a distressing emotion that occurs during various times of the cancer trajectory. Depression often goes unrecognized and untreated, which can significantly affect cost, quality of life, and treatment adherence. The Oncology Nursing Society's Putting Evidence Into Practice depression project team reviewed current literature to identify evidence-based interventions to reduce depression in people with cancer. Pharmacologic and nonpharmacologic interventions were evaluated, and opportunities for nurses to integrate recommendations into practice are offered in this article.

Anxiety and depression-Important psychological comorbidities of COPD

Anxiety and depression are common and important comorbidities in patients with chronic obstructive pulmonary disease (COPD). The pathophysiology of these psychological comorbidities in COPD is complex and possibly explained by common risk factors, response to symptomatology and biochemical alterations. The presence of anxiety and/or depression in COPD patients is associated with increased mortality, exacerbation rates, length of hospital stay, and decreased quality of life and functional status. There is currently no consensus on the most appropriate approach to screening for anxiety and depression in COPD. Treatment options include psychological [relaxation, cognitive behavioural therapy (CBT), self-management] and pharmacological interventions. Although there is some evidence to support these treatments in COPD, the data are limited and mainly comprised by small studies. Pulmonary rehabilitation improves anxiety and depression, and conversely these conditions impact rehabilitation completion rates. Additional high quality studies are urgently required to optimise screening and effective treatment of anxiety and depression in patients with COPD, to enhance complex chronic disease management for these patients.

Explanatory factors for the increased mortality of stroke patients with depression

OBJECTIVE

To identify explanatory factors for the association between depression and increased mortality up to 5 years after stroke.

METHODS

In this cohort study, data from the South London Stroke Register (1998-2013) were used. Patients (n = 3,722) were assessed at stroke onset. Baseline data included sociodemographics and stroke severity. Follow-up at 3 months included assessment for depression with the Hospital Anxiety and Depression Scale (scores ≥7 = depression). Associations between depression at 3 months and mortality within 5 years of stroke were estimated with Cox regression models adjusted for age, sex, ethnicity, and stroke severity, and subsequently adjusted for possible explanatory factors for the association. These factors, introduced into the model individually, included comorbidities at baseline, smoking and alcohol use, compliance with medication, treatment with selective serotonin reuptake inhibitors (SSRIs), social support, and activities of daily living at 3 months.

RESULTS

A total of 1,354 survivors were assessed at 3 months: 435 (32.1%) had depression and 331 (24.4%) died within 5 years. Survivors with depression had a greater risk of mortality (hazard ratio [HR] 1.41 [95% confidence interval (CI) 1.13-1.77]; p = 0.002). The association between depression and mortality was strongest in patients younger than 65 years. Adjustment for comorbidities, smoking and alcohol use, SSRI use, social support, and compliance with medication did not change these associations. SSRIs started after stroke were associated with higher mortality, independently of depression at 3 months (HR 1.72 [95% CI 1.34-2.20]; p < 0.001).

CONCLUSION

Depression after stroke is associated with higher mortality, particularly among younger patients. Stroke survivors taking SSRIs have an increased mortality. The association between depression and mortality is not explained by other individual medical factors.

Reevaluating the role of antidepressants in cancer-related depression: a systematic review and meta-analysis

OBJECTIVE

Prior reviews evaluating the role of antidepressants in cancer-related depression have drawn conflicting conclusions. These reviews have also not explored differences in efficacy and tolerability between antidepressants. We conducted a meta-analysis to address these limitations.

METHOD

We searched Medline (1948-2013), the Cochrane Library (1800-2013), the Cumulative Index to Nursing and Allied Health Literature (1986-2013), ClinicalTrials.gov (2013) and meeting abstracts. We included randomized trials comparing antidepressants to placebo or no treatment for cancer-related depression. We used random effects to calculate standardized mean differences (SMD).

RESULTS

Of 5178 potentially eligible citations, 9 trials (1169 subjects) met inclusion criteria. Trials of mianserin found a robust reduction in depression scores at ≥4 weeks of treatment (SMD: 0.60, 95% confidence interval (CI): 0.24-0.95). Similar, but less robust, results were observed with paroxetine (SMD: 0.22, 95% CI: 0.01-0.42) and fluoxetine (SMD 0.34, 95% CI: 0.02-0.66). Conversely, there was no advantage with amitriptyline or desipramine. Compared to placebo, the odds of dropping out due to side effect were higher with fluoxetine and paroxetine and lower with mianserin. Methodological quality was moderate.

CONCLUSIONS

Paroxetine, fluoxetine and mianserin improve cancer-related depression but may vary in efficacy and tolerability. High-quality, randomized trials of newer antidepressant agents are needed to identify optimal treatments for managing cancer-related depression.

A checklist designed to aid consistency and reproducibility of GRADE assessments: development and pilot validation

BACKGROUND

The grading of recommendation, assessment, development and evaluation (GRADE) approach is widely implemented in health technology assessment and guideline development organisations throughout the world. GRADE provides a transparent approach to reaching judgements about the quality of evidence on the effects of a health care intervention, but is complex and therefore challenging to apply in a consistent manner.

METHODS

We developed a checklist to guide the researcher to extract the data required to make a GRADE assessment. We applied the checklist to 29 meta-analyses of randomised controlled trials on the effectiveness of health care interventions. Two reviewers used the checklist for each paper and used these data to rate the quality of evidence for a particular outcome.

RESULTS

For most (70%) checklist items, there was good agreement between reviewers. The main problems were for items relating to indirectness where considerable judgement is required.

CONCLUSIONS

There was consistent agreement between reviewers on most items in the checklist. The use of this checklist may be an aid to improving the consistency and reproducibility of GRADE assessments, particularly for inexperienced users or in rapid reviews without the resources to conduct assessments by two researchers independently.

Nurses' perceptions of depression in patients with cancer

OBJECTIVE

Our study aimed at examining nurses' perceptions of depression in cancer patients and their role in its management.

METHOD

We employed questionnaire-based semi-directed interviews. Participants were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as "very important," "important," "less important," or "not important" for the diagnosis of depression in cancer patients at two different timepoints (baseline and after a video education program). They were also asked to complete a questionnaire exploring their perceptions about depression and of their role in its systematic screening. We recruited nurses caring for cancer patients from four different departments (palliative care unit, hematology, medical oncology, and thoracic oncology) at an academic medical center.

RESULTS

We interviewed 18 nurses and found that they had a good general knowledge of depression in cancer patients, with the majority of them being able to distinguish specific and important symptoms from nonspecific symptoms. Some nurses considered depression as a second-line symptom, and most did not employ a screening tool in their daily practice. All considered that they had a role to play in the management of depression, even as they acknowledged lacking specific training for that task.

SIGNIFICANCE OF RESULTS

Our results suggest that limited resources—especially lack of training—affects nurses' ability to correctly manage depression in their cancer patients.

Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Depression is a common symptom in people with multiple sclerosis. We systematically reviewed published controlled trials on the effectiveness of cognitive behavioural therapy (CBT) for the treatment of depression in people with multiple sclerosis.

METHODS

Publications were identified using MEDLINE, PsycINFO and the Cochrane Central Register of Controlled Trials to June/July 2013. We combined thesaurus and free-text terms which were synonyms of the concepts multiple sclerosis, depression and cognitive behavioural therapy. We included published controlled trials which compared individual, group CBT, conducted face-to-face or remotely, to no CBT. Two reviewers extracted data to calculate standardized mean differences (SMD) for self-reported symptoms of depression and weighted mean differences (WMD) for the Multiple Sclerosis Impact Scale (MSIS-29), with 95% Confidence Intervals (CIs). We investigated statistical heterogeneity using I².

RESULTS

Seven eligible studies (n = 433) were identified, which evaluated the effect on depression of CBT delivered individually (3 studies), in a group (3 studies) and by computer (1 study). The summary effect (SMD -0.61, 95% CI -0.96 to -0.26, p=0.0006) was reduced (SMD -0.46, 95% CI -0.75 to -0.17, p=0.002) when an outlying study was removed in a sensitivity analysis to examine statistical heterogeneity. Three studies (n=213) observed a direction of effect using the MSIS-29 which was not statistically significant (WMD -4.36, 95% CI -9.33 to 0.62, p=0.09). There was no between-subgroup heterogeneity (I²=0).

CONCLUSIONS

CBT can be an effective treatment for depression in MS. Further research should explore optimal durations and modalities of treatment for patients with different characteristics.

Depression treatment and short-term healthcare expenditures among elderly Medicare beneficiaries with chronic physical conditions

Background

Research on the impact of depression treatment on expenditures is nascent and shows results that vary from negative associations with healthcare expenditures to increased expenditures. However many of these studies did not include psychotherapy as part of the depression treatment. None of these studies included “no treatment” as a comparison group. In addition, no study has included a broad group of chronic physical conditions in studying depression treatment expenditures.

Objective

We determined the association between depression treatment and short-term healthcare expenditures using a nationally representative sample of Medicare beneficiaries with chronic physical conditions and depression.

Method

In this retrospective cohort study, we examined the association between depression treatment in the baseline year and healthcare expenditures in the following year using data from 2000 through 2005 of the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare beneficiaries. Using the rotating panel design of MCBS, we derived five two-year cohorts: 2000–2001, 2001–2002, 2002–2003, 2003–2004, and 2004–2005. The study sample included 1,055 elderly Medicare beneficiaries aged 65 or over. We compared healthcare expenditures of no depression treatment group with depression treatment groups using t-tests. Linear regressions of log-transformed dollars were used to assess the relationship between depression treatment and healthcare expenditures after controlling for demographic, socio-economic, health status, lifestyle risk factors, year of observation and baseline expenditures.

Results

Compared to no depression treatment ($16,795), the average total expenditures were higher for those who used antidepressants only ($17,425) and those who used psychotherapy with or without antidepressants ($19,733). After controlling for the independent variables, antidepressant use and psychotherapy with or without antidepressants were associated with 20.2% (95% CI: 14.1-26.7%) and 29.4% (95% CI: 18.8-41.0%) increase in total expenditures, respectively. We observed that depression treatment was positively associated with inpatient, medical provider and prescription drug expenditures.

Conclusion

Among the elderly Medicare beneficiaries with chronic physical conditions, depression treatment was associated with greater short-term healthcare expenditures. Future research needs to replicate these findings and also examine whether depression treatment reduces expenditures over a longer period of time.

'I know they are distressed. What do I do now?'

Significant advances have been made in our understanding of psychological adjustment to cancer over the last 40 years. Most clinicians now recognise the importance of psychosocial factors and the need for skills in emotional support. In the first phase of psycho-oncology, pioneering work in the 1970s and 1980s mapped the extent of psychological morbidity in cancer. This has been followed by a second phase where clinical trials have demonstrated that psychological treatments are effective. But although clinicians may feel more confident in identifying distress and listening to the patient, they rarely feel confident that they possess the skills to help. This paper will review the progress through the first two phases and argue that we are now in the third phase where we can begin to examine methods for delivering cost-effective psychological care. One of these methods is to equip staff with basic skills to understand and manage psychological distress. This paper will also describe a programme over the last 10 years to evaluate the effectiveness and clinical impact of such training for palliative care professionals.

Complex interventions that reduce urgent care use in COPD: a systematic review with meta-regression

CONTEXT

Chronic obstructive pulmonary disease is common and accounts for considerable healthcare expenditure. A large proportion of this healthcare expenditure is attributable to the use of expensive urgent healthcare. The characteristics of interventions that reduce the use of urgent healthcare remain unclear.

OBJECTIVE

To examine the characteristics of complex interventions intended to reduce the use of urgent and unscheduled healthcare among people with COPD.

DATA SOURCES

Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to 25th January 2013 were conducted. These were supplemented by hand-searching bibliographies and citation tracing identified reviews and eligible studies.

STUDY SELECTION

Studies were eligible for inclusion if they: i) included adults with chronic obstructive pulmonary disease, ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up.

DATA EXTRACTION

Data on the subjects recruited, trial methods used, the characteristics of complex interventions and the effects of the intervention on urgent healthcare utilisation were extracted from eligible studies.

RESULTS

32 independent studies were identified. Pooled effects indicated that interventions were associated with a 32% reduction in the use of urgent healthcare (OR = 0.68, 95% CI = 0.57, 0.80). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.66, 95% CI = 0.55, 0.81), Exercise (OR = 0.60, 95% CI = 0.48, 0.76) and relaxation therapy (OR = 0.48, 95% CI = 0.33, 0.70).

CONCLUSIONS

Use of urgent healthcare in patients with COPD was significantly reduced by complex interventions. Complex interventions among people with COPD may reduce the use of urgent care, particularly those including education, exercise and relaxation.

Evidence of prescription of antidepressants for non-psychiatric conditions in primary care: an analysis of guidelines and systematic reviews

BACKGROUND

Antidepressants (ADs) are commonly prescribed in primary care and are mostly indicated for depression. According to the literature, they are now more frequently prescribed for health conditions other than psychiatric ones. Due to their many indications in a wide range of medical fields, assessing the appropriateness of AD prescription seems to be a challenge for GPs. The aim of this study was to review evidence from guidelines for antidepressant prescription for non-psychiatric conditions in Primary Care (PC) settings.

METHODS

Data were retrieved from French, English and US guideline databases. Guidelines or reviews were eligible if keywords regarding 44 non-psychiatric conditions related to GPs' prescription of ADs were encountered. After excluding psychiatric and non-primary care conditions, the guidelines were checked for keywords related to AD use. The latest updated version of the guidelines was kept. Recent data was searched in the Cochrane Database of Systematic Reviews and in PubMed for updated reviews and randomized control trials (RCTs).

RESULTS

Seventy-eight documents were retrieved and were used to assess the level of evidence of a potential benefit to prescribing an AD. For 15 conditions, there was a consensus that prescribing an AD was beneficial. For 5 others, ADs were seen as potentially beneficial. No proof of benefit was found for 15 conditions and proof of no benefit was found for the last 9. There were higher levels of evidence for pain conditions, (neuropathic pain, diabetic painful neuropathy, central neuropathic pain, migraine, tension-type headaches, and fibromyalgia) incontinence and irritable bowel syndrome. There were difficulties in summarizing the data, due to a lack of information on the level of evidence, and due to variations in efficacy between and among the various classes of ADs.

CONCLUSIONS

Prescription of ADs was found to be beneficial for many non-psychiatric health conditions regularly encountered in PC settings. On the whole, the guidelines were heterogeneous, seemingly due to a lack of trials assessing the role of ADs in treatment strategies.

Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression

BACKGROUND

Depression occurs frequently in patients with diabetes mellitus and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in patients with diabetes and depression.

SEARCH METHODS

Electronic databases were searched for records to December 2011. We searched CENTRAL in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, ISRCTN Register and clinicaltrials.gov. We examined reference lists of included RCTs and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating psychological and pharmacological interventions for depression in adults with diabetes and depression. Primary outcomes were depression and glycaemic control. Secondary outcomes were adherence to diabetic treatment regimens, diabetes complications, death from any cause, healthcare costs and health-related quality of life (HRQoL).

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified publications for inclusion and extracted data from included studies. Random-effects model meta-analyses were performed to compute overall estimates of treatment outcomes.

MAIN RESULTS

The database search identified 3963 references. Nineteen trials with 1592 participants were included. Psychological intervention studies (eight trials, 1122 participants, duration of therapy three weeks to 12 months, follow-up after treatment zero to six months) showed beneficial effects on short (i.e. end of treatment), medium (i.e. one to six months after treatment) and long-term (i.e. more than six months after treatment) depression severity (range of standardised mean differences (SMD) -1.47 to -0.14; eight trials). However, between-study heterogeneity was substantial and meta-analyses were not conducted. Short-term depression remission rates (OR 2.88; 95% confidence intervals (CI) 1.58 to 5.25; P = 0.0006; 647 participants; four trials) and medium-term depression remission rates (OR 2.49; 95% CI 1.44 to 4.32; P = 0.001; 296 participants; two trials) were increased in psychological interventions compared to usual care. Evidence regarding glycaemic control in psychological intervention trials was heterogeneous and inconclusive. QoL did not improve significantly based on the results of three psychological intervention trials compared to usual care. Healthcare costs and adherence to diabetes and depression medication were examined in only one study and reliable conclusions cannot be drawn. Diabetes complications and death from any cause have not been investigated in the included psychological intervention trials.With regards to the comparison of pharmacological interventions versus placebo (eight trials; 377 participants; duration of intervention three weeks to six months, no follow-up after treatment) there was a moderate beneficial effect of antidepressant medication on short-term depression severity (all studies: SMD -0.61; 95% CI -0.94 to -0.27; P = 0.0004; 306 participants; seven trials; selective serotonin reuptake inhibitors (SSRI): SMD -0.39; 95% CI -0.64 to -0.13; P = 0.003; 241 participants; five trials). Short-term depression remission was increased in antidepressant trials (OR 2.50; 95% CI 1.21 to 5.15; P = 0.01; 136 participants; three trials). Glycaemic control improved in the short term (mean difference (MD) for glycosylated haemoglobin A1c (HbA1c) -0.4%; 95% CI -0.6 to -0.1; P = 0.002; 238 participants; five trials). HRQoL and adherence were investigated in only one trial each showing no statistically significant differences. Medium- and long-term depression and glycaemic control outcomes as well as healthcare costs, diabetes complications and mortality have not been examined in pharmacological intervention trials. The comparison of pharmacological interventions versus other pharmacological interventions (three trials, 93 participants, duration of intervention 12 weeks, no follow-up after treatment) did not result in significant differences between the examined pharmacological agents, except for a significantly ameliorated glycaemic control in fluoxetine-treated patients (MD for HbA1c -1.0%; 95% CI -1.9 to -0.2; 40 participants) compared to citalopram in one trial.

AUTHORS' CONCLUSIONS

Psychological and pharmacological interventions have a moderate and clinically significant effect on depression outcomes in diabetes patients. Glycaemic control improved moderately in pharmacological trials, while the evidence is inconclusive for psychological interventions. Adherence to diabetic treatment regimens, diabetes complications, death from any cause, health economics and QoL have not been investigated sufficiently. Overall, the evidence is sparse and inconclusive due to several low-quality trials with substantial risk of bias and the heterogeneity of examined populations and interventions.

Older adults with severe, treatment-resistant depression

Depression is a common, disabling, and costly condition encountered in older patients. Effective strategies for detection and treatment of late-life depression are summarized based on a case of a 69-year-old woman who struggled with prolonged depression. Clinicians should screen older patients for depression using a standard rating scale, initiate treatment such as antidepressant medications or evidence-based psychotherapy, and monitor depression symptoms. Patients who are not improving should be considered for psychiatric consultation and treatment changes including electroconvulsive therapy. Several changes in treatment approaches are usually needed before patients achieve complete remission. Maintenance treatment and relapse-prevention planning (summarization of early warning signs for depression, maintenance treatments such as medications, and other strategies to reduce the risk of relapse [eg, regular physical activity or pleasant activities]) can reduce the risk of relapse. Collaborative programs, in which primary care clinicians work closely with mental health specialists following a measurement-based treatment-to-target approach, are significantly more effective than typical primary care treatment.

Inappropriate prescriptions of antidepressant drugs in patients with subthreshold to mild depression: time for the evidence to become practice

Recent studies indicate that antidepressant drugs are largely ineffective in patients with subthreshold to mild depression when compared to placebo. In spite of this evidence, researchers continue to judge the prescription of antidepressant drugs to patients with subthreshold to mild depression as an adequate treatment, which in turn serves to further reinforce the undifferentiated treatment strategy adopted by clinicians. The present narrative review critically reflects on current research practice and highlights the need for a more differentiated, evidence-based clinical and research practice.

Predictors of non-remission of depression in a palliative care population

BACKGROUND

Prospective studies of depression in palliative care are rare. Two studies that examine depression prospectively in patients with advanced disease have not looked at predictors of remission.

AIMS

to explore prospective predictors of non-remission of depression in palliative care.

DESIGN AND PARTICIPANTS

The study design comprised two data collections: initial assessment on referral to a palliative care service in South London, UK, and a four-week follow-up. Seventy six participants met the criteria for 'any depressive syndrome' at the time 1 assessment, using the PRIME-MD, who also participated at time 2. The outcome measure was remission (N = 39) or non-remission (N = 37) of depression by time 2.

RESULTS

The findings showed that reporting low social support from family and friends at time of referral was the most powerful risk factor for non-remission. There was also a strong association between improved physical symptoms, from time 1 to 2, and remission of depression.

CONCLUSIONS

This study in palliative care is the first of which we are aware to explore factors associated with non-remission of depression. Depressed patients identified with low social support on referral to palliative care services might particularly benefit from additional psychosocial care in the treatment of their depression. This study provides evidence that effective physical symptom management in palliative care may be a valuable intervention for depressive symptoms.

Evidence-Based Treatment of Depression in Patients With Cancer

Purpose

Depression is a common condition in patients with cancer, although there has been a relative paucity of research on the effectiveness of treatment in this population. This review summarizes the psychosocial and pharmacologic treatment of depression in patients with cancer based on a consideration of evidence regarding etiologic factors and treatment outcomes.

Methods

A review of the evidence base for psychosocial and pharmacologic interventions for depression in patients with cancer was performed, including original studies, systematic reviews, and meta-analytic studies in the literature.

Results

Recent evidence from randomized controlled trials has demonstrated the efficacy of psychosocial and pharmacologic treatments to alleviate depression in patients with cancer. Further research is needed to establish their relative and combined efficacy and their role in the treatment of depression that is less severe and occurs in association with more advanced disease. First-line recommendations for the treatment of depression in patients with cancer are difficult to derive based on current evidence, because comparative studies have not been conducted to support the superiority of one treatment modality over another in this population.

Conclusion

Both psychosocial and pharmacologic interventions have been shown to be efficacious in treating depression in cancer, but further research is needed to establish their relative and combined benefit. Future research directions include the development and evaluation of novel interventions targeted to specific biologic and psychosocial risk factors.

Observational evidence that urbanisation and neighbourhood deprivation are associated with escalation in chronic pharmacological pain treatment: a longitudinal population-based study in the Netherlands

OBJECTIVE

To examine, in the light of the association between urban environment and poor mental health, whether urbanisation and neighbourhood deprivation are associated with analgesic escalation in chronic pharmacological pain treatment and whether escalation is associated with prescriptions of psychotropic medication.

DESIGN

Longitudinal analysis of a population-based routine dispensing database in the Netherlands.

SETTING

Representative sample of pharmacies, covering 73% of the Dutch nationwide medication consumption in the primary care and hospital outpatient settings.

PARTICIPANTS

449 410 patients aged 15-85 years were included, of whom 166 374 were in the Starter group and 283 036 in the Continuation group of chronic analgesic treatment.

MAIN OUTCOME MEASURE

Escalation of analgesics (ie, change to a higher level of analgesic potency, classified across five levels) in association with urbanisation (five levels) and dichotomous neighbourhood deprivation was analysed over a 6-month observation period.

METHODS

Ordered logistic multivariate model evaluating analgesic treatment.

RESULTS

In both Starter and Continuation groups, escalation was positively associated with urbanisation in a dose-response fashion (Starter group: OR (urbanisation level 1 compared with level 5): 1.24, 95% CI 1.18 to 1.30; Continuation group: OR 1.18, 95% CI 1.14 to 1.23). An additional association was apparent with neighbourhood deprivation (Starter group: OR 1.07, 95% CI 1.02 to 1.11; Continuation group: OR 1.04, 95% CI 1.01 to 1.08). Use of somatic and particularly psychotropic co-medication was associated with escalation in both groups.

CONCLUSIONS

Escalation of chronic analgesic treatment is associated with urban and deprived environments and occurs in a context of adding psychotropic medication prescriptions. These findings suggest that pain outcomes and mental health outcomes share factors that increase risk and remedy suffering.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in patients with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH STRATEGY

CENTRAL, DARE, HTA and EED on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ISRCTN Register and CardioSource Registry were searched. Reference lists of included randomised controlled trials (RCTs) were examined and primary authors contacted. No language restrictions were applied.

SELECTION CRITERIA

RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression were included. Primary outcomes were depression, mortality and cardiac events. Secondary outcomes were healthcare costs and health-related quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two reviewers independently examined the identified papers for inclusion and extracted data from included studies. Random effects model meta-analyses were performed to compute overall estimates of treatment outcomes.

MAIN RESULTS

The database search identified 3,253 references. Sixteen trials fulfilled the inclusion criteria. Psychological interventions show a small beneficial effect on depression compared to usual care (range of SMD of depression scores across trials and time frames: -0.81;0.12). Based on one trial per outcome, no beneficial effects on mortality rates, cardiac events, cardiovascular hospitalizations and QoL were found, except for the psychosocial dimension of QoL. Furthermore, no differences on treatment outcomes were found between the varying psychological approaches. The review provides evidence of a small beneficial effect of pharmacological interventions with selective serotonin reuptake inhibitors (SSRIs) compared to placebo on depression outcomes (pooled SMD of short term depression change scores: -0.24 [-0.38,-0.09]; pooled OR of short term depression remission: 1.80 [1.18,2.74]). Based on one to three trials per outcome, no beneficial effects regarding mortality, cardiac events and QoL were found. Hospitalization rates (pooled OR of three trials: 0.58 [0.39,0.85] and emergency room visits (OR of one trial: 0.58 [0.34,1.00]) were reduced in trials of pharmacological interventions compared to placebo. No evidence of a superior effect of Paroxetine (SSRI) versus Nortriptyline (TCA) regarding depression outcomes was found in one trial.

AUTHORS' CONCLUSIONS

Psychological interventions and pharmacological interventions with SSRIs may have a small yet clinically meaningful effect on depression outcomes in CAD patients. No beneficial effects on the reduction of mortality rates and cardiac events were found. Overall, however, the evidence is sparse due to the low number of high quality trials per outcome and the heterogeneity of examined populations and interventions.

Depression in relation to anxiety, obsessionality and phobia among neurosurgical patients with a primary brain tumor: a 1-year follow-up study

Depression is found to be present in up to 44% of brain tumor patients during their illness process. Anxiety as a comorbid psychiatric disorder with depression has formerly been studied, but phobia or obsessive-compulsive symptoms among brain tumor patients have not yet been noticed. By using a clinical prospective database of primary brain tumor patients (n=77) we studied the level of depression, anxiety, obsessionality (traits and symptoms) and phobic anxiety symptoms. Psychiatric symptoms were assessed before tumor operation as well as at three months and at one year after operation. The presence of comorbid anxiety, obsessionality and phobic anxiety symptoms was assessed before operation and at follow-ups in depressed and non-depressed patients, separately. Before tumor operation 16% of the patients had depression according to Beck Depression Inventory (BDI), while 10% had depression at three months and 15% at one year after operation. The depressed patients had statistically significantly higher anxiety scores and phobic scores at all three measurement points compared to corresponding scores among non-depressed brain tumor patients. The mean obsessionality scores among depressed brain tumor patients were significantly higher when measured before operation and at one year after the operation compared to non-depressed patients. To our knowledge, this is the first study so far in which comorbidity of psychiatric symptoms has been shown among depressive brain tumor patients. Concurrent comorbid conditions have been shown to be associated with increased severity, morbidity and chronicity of depression. It is recommended that treatment of depressive patients complicated with comorbid psychiatric disorders be planned by psychiatric units.

Expert opinion on detecting and treating depression in palliative care: A Delphi study

BACKGROUND

There is a dearth of data regarding the optimal method of detecting and treating depression in palliative care. This study applied the Delphi method to evaluate expert opinion on choice of screening tool, choice of antidepressant and choice of psychological therapy. The aim was to inform the development of best practice recommendations for the European Palliative Care Research Collaborative clinical practice guideline on managing depression in palliative care.

METHODS

18 members of an international, multi-professional expert group completed a structured questionnaire in two rounds, rating their agreement with proposed items on a scale from 0-10 and annotating with additional comments. The median and range were calculated to give a statistical average of the experts' ratings.

RESULTS

There was contention regarding the benefits of screening, with 'routine informal asking' (median 8.5 (0-10)) rated more highly than formal screening tools such as the Hospital Anxiety and Depression Scale (median 7.0 (1-10). Mirtazapine (median 9 (7-10) and citalopram (median 9 (5-10) were the considered the best choice of antidepressant and cognitive behavioural therapy (median 9.0 (3-10) the best choice of psychological therapy.

CONCLUSIONS

The range of expert ratings was broad, indicating discordance in the views of experts. Direct comparative data from randomised controlled trials are needed to strengthen the evidence-base and achieve clarity on how best to detect and treat depression in this setting.

The clinical epidemiology of depression in palliative care and the predictive value of somatic symptoms: cross-sectional survey with four-week follow-up

This cross-sectional survey aimed to determine the prevalence and remission of depression in patients receiving palliative care and to ascertain the predictive value of somatic symptoms in making the diagnosis. Three hundred consecutive patients were interviewed within one week of their initial assessment by a specialist nurse at a palliative care service with in-patient and homecare facilities in south London, UK. Depression was assessed using the PRIME-MD PHQ-9. Presence of somatic symptoms (fatigue, sleep disturbance, poor appetite) was determined using the EORTC-QLQ-C30 quality of life questionnaire. Fifty-eight (19.3% [15.3 to 23.3]) patients met criteria for Major Depressive Disorder; 109 (36.3% [32.3 to 40.3]) met criteria for 'Any depressive syndrome'. Patients with Major Depressive Disorder were more likely to be male, and to have non-malignant disease, pain, poor performance status and desire for an early death. Of those patients with Major Depressive Disorder at baseline, 69% (27/39) had remitted four weeks later. Of those not depressed at baseline, 11% (19/174) met criteria for depression at follow-up. The positive predictive values of sleep disturbance, poor appetite and fatigue were low (<24%), whereas the negative predictive values of these symptoms were high (>89%). The high prevalence of depression in palliative care attests to the need for psychological assessment and support. Depression in patients receiving palliative care is unstable, suggesting that symptoms should be carefully monitored.

Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis

Depression can exacerbate symptoms associated with life-threatening illness and increase disability and distress. In palliative care, depression occurs in a context of multiple symptoms, which complicates detection and treatment. While systematic reviews of antidepressants have been conducted in specific life-threatening diseases, no previous study has synthesized the evidence in palliative care. The objective of this study was to determine the efficacy of antidepressants for the treatment of depression in palliative care. MEDLINE, EMBASE, PSYCINFO and Cochrane trials registers were systematically searched to identify randomized controlled trials comparing antidepressants and placebo for the treatment of depression in palliative care. The primary outcome was efficacy assessed at three time-points. Twenty-five studies were included in the review. At each time-point antidepressants were more efficacious than placebo: 4-5 weeks odds ratio (OR) 1.93 (1.15-3.42) p = 0.001; 6-8 weeks OR 2.25 (1.38-3.67) p = 0.001; 9-18 weeks OR 2.71 (1.50-4.91) p = 0.001. This review provides evidence that antidepressants are effective in treating depression in palliative care. Their superiority over placebo is apparent within 4-5 weeks and increases with continued use. It is probable that the effect sizes yielded in this review overestimate the efficacy of antidepressants due to biases such as selective reporting and publication. Nevertheless, the magnitude and consistency of the effect suggests genuine benefit.

Emerging strategies in the treatment of poststroke depression and psychiatric distress in patients

Poststroke depression (PSD) is a common sequela of stroke associated with increased morbidity and mortality among stroke survivors. PSD has been associated with poorer rehabilitative outcomes, longer inpatient stays, inefficient use of medical resources, worsened cognitive decline, and increased suicidality. This article reviews the definition and proposed etiology of PSD as well as current and emerging evidence-based prevention, screening, and treatment modalities. The timely use of prevention and treatment techniques including pharmacologic and nonpharmacologic methods may improve treatment outcomes and enhance the quality of life in stroke patients.