Incorporating multidimensional patient-reported outcomes of symptom severity, functioning, and quality of life in the Individual Burden of Illness Index for Depression to measure treatment impact and recovery in MDD

Utility of the Work and Social Adjustment Scale (WSAS) in predicting long-term sick-leave in Danish patients with emotional disorders

BACKGROUND

The Work and Social Adjustment Scale (WSAS) is a self-administered measure designed to assess the level of inability to function socially as a consequence of a defined problem or disorder.

METHODS

A total of 230 patients with emotional disorders completed the Danish translation of the WSAS, measures of anxiety and depression, the Level of Personality Functioning Brief Form, the Personality Inventory for DSM-5 Short Form, and the World Health Organization Five-Item Well-Being Index (WHO-5). We conducted a confirmatory factor analysis of the previously suggested factor structure of the instrument. We furthermore evaluated the construct validity of the WSAS by means of its relationship with depression, anxiety, personality functioning, and overall well-being. Finally, we evaluated the utility of the WSAS to identify those on long-term sick-leave by conducting receiver operating characteristic (ROC) curves.

RESULTS

The instrument had a poor to average fit with the previously reported single-factor structure, but a better fit to a modified single-factor structure. Cronbach's alpha and McDonald's omega showed good internal scale reliability (α = .79, ωtotal = .85). WSAS was positively correlated with measures of anxiety (r = .33), depression (r = .44), and personality functioning (r = .23 and r = .20), and negatively correlated with WHO-5 wellbeing (r = -.57). The optimal cut-off point in the ROC-analyses was 23, which yielded a sensitivity of 74% and a specificity of 55% in the prediction of sick-leave status.

DISCUSSION

The Danish WSAS shows promising psychometric properties, but has limited external validity insofar as predicting long-term sick leave in psychiatric patients with emotional disorders.

Predictors of Changes in Quality of Life of Patients with Major Depressive Disorder-A Prospective Naturalistic 3-Month Follow-Up Study

Major depressive disorder (MDD) is one of the leading causes of disease burden worldwide and affected patients frequently report impairments in quality of life (QoL). Therefore, the present research aimed to identify predictors of domain-specific QoL changes in MDD patients following the acute phase of pharmacological treatment (3-month). This study is a prospective, naturalistic, and observational analysis on 150 patients. Depressive symptoms, QoL, overall pain intensity, and functionality were assessed using Hamilton Depression Rating Scale, World Health Organization Quality of Life scale-abbreviated version, Visual Analog Scale, and Sheehan Disability Scale, respectively. Reductions in symptom severity and disability were predictors of improvement across all domains of QoL. Pain intensity reduction was a predictor of increases in the physical aspect of QoL. A reduced number of psychiatric hospitalizations and being in a relationship predicted an improvement of QoL in the psychological domain whereas a positive history of suicidal attempts was associated with better social relationships QoL. The predictive models explained 41.2% and 54.7% of the variance in psychological and physical health domains of QoL, respectively. Awareness of sociodemographic and changes in clinical factors that impact the change in domain-specific QoL might help in shaping personalized treatment.

Impact of response shift effects in the assessment of self-reported depression during treatment: Insights from a rTMS versus Venlafaxine randomized controlled trial

PURPOSE

Patient-Reported Outcomes are essential to properly assess treatment effectiveness in randomized clinical trial (RCT) for Major Depressive Disorder (MDD). MDD self-assessment may vary over time depending on change in the meaning of patients' self-evaluation of depression, i.e. Response Shift (RS). Our aim was to investigate RS and its impact on different depression domains in a clinical trial comparing rTMS versus Venlafaxine.

METHODS

The occurrence and type of RS was determined using Structural Equation Modeling applied to change over time in 3 domains (Sad Mood, Performance Impairment, Negative Self-Reference) of the short-form Beck Depression Inventory (BDI-13) in a secondary analysis of a RCT on 170 patients with MDD treated by rTMS, venlafaxine or both.

RESULTS

RS was evidenced in the venlafaxine group in the Negative Self-Reference and Sad Mood domains.

CONCLUSION

RS effects differed between treatment arms in self-reported depression domains in patients with MDD. Ignoring RS would have led to a slight underestimation of depression improvement, depending on treatment group. Further investigations of RS and advancing new methods are needed to better inform decision making based on Patient-Reported Outcomes.

The Brief Multidimensional Assessment Scale (BMAS): A Broad Measure of Patient Well-Being

OBJECTIVE

This article discusses the development and initial clinimetric and psychometric properties of the Brief Multidimensional Assessment Scale (BMAS). The BMAS is an ultrabrief multidimensional measure of global patient well-being that can be used at every clinic visit to assess several facets of patients' perception of themselves, regardless of their diagnosis, at a moment in time and over the course of treatment.

METHODS

Data were collected from 499 adults in the community as well as from psychiatric and medical inpatient and outpatient settings. Participants completed questionnaires as part of their standard care at inpatient and outpatient medical and psychiatric settings or completed them online (community sample).

RESULTS

Results indicate that the BMAS measures four discrete dimensions: the ability to get things done, emotional support in important relationships, quality of life, and sense of purpose in life. The scale demonstrates concurrent validity with other measures and discriminates between nonclinical participants and participants from most clinical contexts.

CONCLUSIONS

The BMAS demonstrates promising initial psychometric properties. It offers clinicians a multidimensional measure of their patients' well-being, regardless of diagnosis, that can be used to monitor well-being at each routine appointment and over time.

The relative importance of diagnostic specific and transdiagnostic factors in evaluating treatment outcome of depressed patients

Determinations of the efficacy of treatments for depression most commonly are based on changes in scores on symptom severity scales. This narrow symptom-focused approach towards evaluating outcome is at variance with patients' broader conceptualization of the factors deemed important in evaluating the outcome of depression treatment. In the present report we examine the factors associated with depressed patients' global ratings of improvement after a treatment intervention. Five hundred and three patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. The patients completed the RDQ at admission and discharge from the treatment program. At discharge, the patients made a global rating of the effectiveness of treatment. The patients significantly improved from admission to discharge on each RDQ subscale. Changes in the well-being/life satisfaction and coping subscales were the only 2 subscales that were independently associated with the patients' ratings of improvement. These results suggest that when evaluating outcome in the treatment of depression a focus on symptom improvement is too narrow. Consideration of a broader perspective in measuring outcome in treatment studies of depression is more consistent with a biopsychosocial conceptualization.

Assessing the Burden of Illness Associated with Acquired Generalized Hypoactive Sexual Desire Disorder

Background:

Hypoactive sexual desire disorder (HSDD), which affects ∼10% of women in the United States, is defined as the persistent or recurrent deficiency/absence of sexual desire accompanied by personal distress. Although HSDD impacts patient quality of life and interpersonal relationships, the disorder often goes unaddressed or untreated. Recent studies of the burden of illness in women with HSDD, especially premenopausal women, are limited.

Materials and Methods:

A 45-minute web-based survey was designed to investigate the experience of women seeking treatment for HSDD and the impact of this disorder on several psychosocial aspects of women's lives. Women were recruited from an online panel of patients who participated in research studies for compensation. Validated questionnaires assessed sexual function (Female Sexual Function Index) and health-related quality of life (12-Item Short Form Survey [SF-12]), including mental and physical component scores.

Results:

A total of 530 women, aged ≥18 years, diagnosed with acquired generalized HSDD were included in the study. Premenopausal women indicated greater overall HSDD symptom burden compared with postmenopausal women. Patients with HSDD reported lower SF-12 scores compared with the general population. A multivariable regression analysis demonstrated that psychosocial factors influencing the burden of HSDD, including interference with their relationship with their partner (β = −0.18; p < 0.005), mental and emotional well-being (β = −0.23; p < 0.005), and household and personal activities (β = −0.23; p = 0.02), negatively affected SF-12 mental component scores.

Conclusions:

HSDD symptom burden was found to be negatively and statistically significantly associated with patients' mental health; the impact was greater among premenopausal women compared with postmenopausal women.

Clinical research challenges posed by difficult-to-treat depression

Approximately one-third of individuals in a major depressive episode will not achieve sustained remission despite multiple, well-delivered treatments. These patients experience prolonged suffering and disproportionately utilize mental and general health care resources. The recently proposed clinical heuristic of 'difficult-to-treat depression' (DTD) aims to broaden our understanding and focus attention on the identification, clinical management, treatment selection, and outcomes of such individuals. Clinical trial methodologies developed to detect short-term therapeutic effects in treatment-responsive populations may not be appropriate in DTD. This report reviews three essential challenges for clinical intervention research in DTD: (1) how to define and subtype this heterogeneous group of patients; (2) how, when, and by what methods to select, acquire, compile, and interpret clinically meaningful outcome metrics; and (3) how to choose among alternative clinical trial design options to promote causal inference and generalizability. The boundaries of DTD are uncertain, and an evidence-based taxonomy and reliable assessment tools are preconditions for clinical research and subtyping. Traditional outcome metrics in treatment-responsive depression may not apply to DTD, as they largely reflect the only short-term symptomatic change and do not incorporate durability of benefit, side effect burden, or sustained impact on quality of life or daily function. The trial methodology will also require modification as trials will likely be of longer duration to examine the sustained impact, raising complex issues regarding control group selection, blinding and its integrity, and concomitant treatments.

Transdiagnostic and functional predictors of depression severity and trajectory in the Penn state psychiatry clinical assessment and rating evaluation system (PCARES) registry

BACKGROUND

Timely, accurate diagnosis and subsequent identification of risk factors for depression that is difficult-to-treat can aid in decreasing the burden of depressive illness and reducing probability of future disability. We aimed to identify sociodemographic, clinical, and functional factors that predict depression severity over one year in a real-world, naturalistic, transdiagnostic clinical sample. A subset sample with moderate depression was examined to determine the magnitude of improvement.

METHODS

The Penn State Psychiatry Clinical Assessment and Rating System (PCARES) Registry houses data from systematically-structured patient-reported outcomes and clinical data from an Electronic Medical Record (EMR) gathered during routine clinical care of patients seeking mental health care at a mid-Atlantic clinic. Self-report symptom and functional measures were obtained, and sociodemographic features and clinical diagnoses were extracted from the EMR from 1,766 patients between 2/6/2016 to 9/30/2019. The Patient Health Questionnaire 9 (PHQ-9) depression scale was obtained at each visit. Using a discrete mixture clustering model, the study population was divided into five longitudinal trajectory groups, termed depression severity groups, based on intra-individual PHQ-9 score trajectories over one year. Multinomial logistic regression models were estimated to evaluate associations between characteristics and the likelihood of depression severity group membership. To determine the magnitude of improvement, predictors of the slope of the PHQ-9 trajectory were examined for patients with moderate depression.

RESULTS

The strongest predictors of high depression severity over one year were poor functioning, high transdiagnostic DSM-5 Level 1 crosscutting symptom score, diagnosis of Post-Traumatic Stress Disorder (PTSD), public/self-pay insurance, female gender, and non-White race. Among the subset of patients with moderate depression, strong predictors of improvement were commercial insurance and exposure to trauma; the strongest predictors of worsening were high functional impairment, high transdiagnostic Level 1 symptom score, diagnosis of PTSD, diagnosis of bipolar disorder, and marital status of single or formerly married; depression-specific symptom measures were not predictive.

LIMITATIONS

Limitations include inferring education and income status from zip code level-data, the non-random missingness of data, and the use of diagnoses collected from the electronic medical record.

CONCLUSION

Functional impairment, transdiagnostic measures of symptom burden, and insurance status are strong predictors of depression severity and poor outcome.

Functional outcomes with bright light in monotherapy and combined with fluoxetine in patients with major depressive disorder: Results from the LIFE-D trial

BACKGROUND

Bright light therapy has been shown to improve depressive symptoms in patients with nonseasonal major depressive disorder (MDD) but there are few studies examining functional outcomes.

METHODS

We examined secondary functional outcomes in the 8-week randomized, placebo-sham-controlled LIFE-D trial comparing light therapy, fluoxetine, and the combination in patients with nonseasonal MDD. Functional assessments included the Sheehan Disability Scale (SDS) and, for employed participants, the Lam Employment Absence and Productivity Scale (LEAPS). Analysis of covariance (ANCOVA) was conducted with SDS and LEAPS change scores from baseline to week 8 as dependent variables, treatment modality (light, fluoxetine) as an independent variable, and baseline SDS and LEAPS scores as covariates.

RESULTS

Of 122 randomized participants, SDS data were available for 105 and LEAPS data for 70. For the SDS, there were no interaction effects, but there was a significant small- to medium-sized main effect of light treatment on total SDS scores with corresponding significant effects in the Social Life and Family Life domains, but not in the Work/Study domain. There were no significant interaction or main effects with LEAPS scores.

CONCLUSION

Light therapy significantly improved social and family life functioning in patients with MDD. However, work functioning was not significantly improved despite large effect sizes; these results were limited by low statistical power because of small sample sizes. Future studies should use longer treatment durations and be powered to detect clinically relevant differences in functional outcomes.

Involvement of oxidative pathways and BDNF in the antidepressant effect of carvedilol in a depression model induced by chronic unpredictable stress

RATIONALE

Depression is a severe psychiatric disorder with oxidative imbalance and neurotrophic deficits as underlying mechanisms.

OBJECTIVES

Based on the antioxidant effects of carvedilol (CARV), here, we aimed to evaluate CARV's effects against depression induced by the chronic unpredictable stress (CUS) model.

METHODS

Female Swiss mice were submitted to the CUS protocol for 21 days. Between days 15 and 22, the animals received CARV (5 or 10 mg/kg) or desvenlafaxine (DVS 10 mg/kg) orally. On the 22nd day, mice were subjected to behavioral tests to evaluate locomotion, depressive-like behavior (tail suspension test), motivation/self-care with the splash test (ST), social interaction, and working memory Y-maze test. The prefrontal cortex (PFC) and hippocampus were dissected to evaluate alterations of oxidative and brain-derived neurotrophic factor (BDNF).

RESULTS

The CUS model reduced locomotion and increased grooming latency, while it reduced the number of groomings in the ST. Both doses of CARV and DVS reverted these alterations. In addition, DVS and CARV reversed CUS model-induced working memory and social interaction deficits. The CUS model decreased hippocampal reduced glutathione (GSH), while DVS and CARV increased GSH in the PFC (CARV5) and hippocampus (CARV5 and 10). The CUS model increased nitrite and malondialdehyde (MDA) concentrations in both areas. All treatments reversed nitrite alterations, while CARV10 changed MDA levels in PFC and all treatments in the hippocampus. The CUS model reduced BDNF levels. CARV10 increased BDNF in the PFC, while both doses of CARV increased hippocampal levels of this neurotrophin.

CONCLUSIONS

CARV presents antidepressant-like effects comparable to those observed with DVS. In addition, it has an antioxidant effect and is capable of increasing BDNF brain concentrations. Further studies are needed to elucidate the mechanisms involved in the antidepressant effect of CARV.

Changes in Presenteeism Six Months After Returning from Sick Leave Due to Mental Illness

This study examines how psychological distress (measured by the K10 screening test) and presenteeism (measured by the quality and quantity method) change in the six months after returning to work from having taken a sick leave because of a mental illness. In a manufacturing company with approximately 2,600 employees, 23 employees returned to work after experiencing mental illness between April 2015 and March 2016, and all 23 agreed to participate in the study. We analyzed 18 cases for which we had sufficient data. Two of the employees were absent from work in the sixth month. We performed multilevel analysis for K10 and presenteeism over time on the 16 without recurrence. A significant decreasing trend was observed for both K10 and presenteeism. Eleven of the 16 employees were consistently below the K10 cutoff value of 10 for six months, and 5 had zero presenteeism in the sixth month, whereas 6 employees showed improvement in presenteeism that stopped midway through the study. An occupational physician judged that the employees could work normally with presenteeism of zero. After returning to work, it is important to monitor not only psychiatric symptoms but also presenteeism.

Validation of the German version of the work and social adjustment scale in a sample of depressed patients

BACKGROUND

Depression is one of the key factors contributing to difficulties in one's ability to work, and serves as one of the major reasons why employees apply for psychotherapy and receive insurance subsidization of treatments. Hence, an increasing and growing number of studies rely on workability assessment scales as their primary outcome measure. The Work and Social Assessment Scale (WSAS) has been documented as one of the most psychometrically reliable and valid tools especially developed to assess workability and social functioning in patients with mental health problems. Yet, the application of the WSAS in Germany has been limited due to the paucity of a valid questionnaire in the German language. The objective of the present study was to translate the WSAS, as a brief and easy administrable tool into German and test its psychometric properties in a sample of adults with depression.

METHODS

Two hundred seventy-seven patients (M = 48.3 years, SD = 11.1) with mild to moderately severe depression were recruited. A multistep translation from English into the German language was performed and the factorial validity, criterion validity, convergent validity, discriminant validity, internal consistency, and floor and ceiling effects were examined.

RESULTS

The confirmatory factor analysis results confirmed the one-factor structure of the WSAS. Significant correlations with the WHODAS 2-0 questionnaire, a measure of functionality, demonstrated good convergent validity. Significant correlations with depression and quality of life demonstrated good criterion validity. The WSAS also demonstrated strong internal consistency (α = .89), and the absence of floor and ceiling effects indicated good sensitivity of the instrument.

CONCLUSIONS

The results of the present study demonstrated that the German version of the WSAS has good psychometric properties comparable to other international versions of this scale. The findings recommend a global assessment of psychosocial functioning with the sum score of the WSAS.

TRIAL REGISTRATION

ISRCTN identifier: ISRCTN28972230 . Date of registration June 26th 2018.

Predictors and moderators of quality of life in patients with major depressive disorder: An AGTs-MDD study report

Effective and targeted interventions for improving quality of life (QOL) in addition to achieving 'clinical remission' are imperatives for patients with major depressive disorder (MDD). This study aimed to examine potential predictors and moderators of QOL in depression. Data were obtained from the Algorithm Guided Treatment Strategies for Major Depressive Disorder (AGTs-MDD) study, a multisite, randomized controlled trial composed of 980 depressed patients. Mixed Model Repeated Measures (MMRM) analyses were conducted to identify baseline characteristics associated with QOL overall (predictors) and their interaction effects (moderators). Severe core depressive, anxiety and pain symptoms were found to be independently associated with poor QOL over the 12-week acute phase treatment. Severe depression, severe anxiety or pain symptoms, or severe suicidal ideation predicted a larger improvement of QOL during acute phase treatment, whereas males showed less improvement. None of the putative moderators were identified except for the educational level. Patients with lower educational level showed a larger improvement of QOL in the AGT started with escitalopram (AGT-E) group and AGT started with mirtazapine (AGT-M) group compared to the treatment as usual (TAU) group. These findings may help to instruct informed decision-making for heterogeneous patients with MDD in the view of full recovery.

Predictors of Quality of Life Improvement with Escitalopram and Adjunctive Aripiprazole in Patients with Major Depressive Disorder: A CAN-BIND Study Report

BACKGROUND

Non-response to first-line treatment for major depressive disorder (MDD) is common; for such individuals, quality of life (QoL) impairments can be severe. Identifying predictors of QoL changes may support the management of cases with persistent depressive symptoms despite adequate initial pharmacological/psychological treatment.

OBJECTIVE

The present study aimed to explore predictors of domain-specific QoL improvement following adjunctive aripiprazole treatment for inadequate response to initial antidepressant therapy.

METHODS

We evaluated secondary QoL outcomes from a CAN-BIND (Canadian Biomarker Integration Network in Depression) study in patients with MDD who did not respond to an initial 8 weeks of escitalopram and received a further 8 weeks of adjunctive aripiprazole (n = 96). Physical, psychological, social, and environmental QoL domains were assessed using the World Health Organization QoL Scale Brief Version (WHOQOL-BREF). Clinician-rated depressive symptoms were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS). Functioning was measured with the Sheehan Disability Scale (SDS). Satisfaction with medication was assessed with a single item from the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Exploratory t-tests were used to describe domain score changes. A hierarchical linear regression was used to explore demographic, clinical, and treatment-related predictors of improvement.

RESULTS

Across domains, QoL improved with adjunctive aripiprazole treatment. Satisfaction with medication and MADRS and SDS scores similarly improved. Symptom reduction was a predictor for positive change to physical and psychological QoL; functioning improvements were predictive of increases to all QoL domains. Satisfaction with medication predicted improvements to physical and psychological domains, whereas number of medication trials was a predictor of worsening QoL in the physical domain.

CONCLUSION

The final model explained the most variance in psychological (68%) and physical (67%) QoL. Less variance was explained for environmental (43%) and social QoL (33%), highlighting a need for further exploration of predictors in these domains. Strategies such as functional remediation may have potential to support QoL for individuals with persistent depressive symptoms.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov identifier: NCT016557.

Impacts on Quality of Life with Escitalopram Monotherapy and Aripiprazole Augmentation in Patients with Major Depressive Disorder: A CAN-BIND Report

INTRODUCTION

Many individuals with major depressive disorder (MDD) do not respond to initial antidepressant monotherapy. Adjunctive aripiprazole is recommended for treatment non-response; however, the impacts on quality of life (QoL) for individuals who receive this second-line treatment strategy have not been described.

METHODS

We evaluated secondary QoL outcomes in patients with MDD (n=179). After 8 weeks of escitalopram, non-responders (<50% decrease in clinician-rated depression) were treated with adjunctive aripiprazole for 8 weeks (n=97); responders continued escitalopram (n=82). A repeated-measures ANOVA evaluated change in Quality of Life Enjoyment and Satisfaction Short Form scores. QoL was described relative to normative benchmarks.

RESULTS

Escitalopram responders experienced the most QoL improvements in the first treatment phase. For non-responders, QoL improved with a large effect during adjunctive aripiprazole treatment. At the endpoint, 47% of patients achieving symptomatic remission still had impaired QoL.

DISCUSSION

Individuals who were treated with adjunctive aripiprazole after non-response to escitalopram experienced improved QoL, but a substantial degree of QoL impairment persisted. Since QoL deficits may predict MDD recurrence, attention to ways to support this outcome is required.

Profiles of depression in a treatment-seeking Hispanic population: Psychometric properties of the Patient Health Questionnaire-9

OBJECTIVES

Screening instruments can be powerful tools in assisting primary care providers with detecting depression in their patients and monitoring treatment response. Health disparities among racial and ethnic minorities result from inaccurate assessment in primary care.

METHODS

The current study used baseline data from two federally funded research studies of treatment for depression among Hispanics in primary care. The Patient Health Questionnaire-9 (PHQ-9) was administered at baseline prior to the study interventions, and 499 participants provided responses.

RESULTS

Confirmatory factor analyses found excellent factor validity for the PHQ-9, yet reliability remained poor. Possible heterogeneity in depressive item scores was examined, and latent profile analysis identified four distinct profiles of PHQ-9 responses. Profiles included a lower depression, moderate/somatization, moderate/negative self-view, and severe depression profiles. Results indicate modest support for the PHQ-9 and its use among Hispanics for the purpose of depression screening.

CONCLUSION

Capturing four profiles of depression in a large primary care sample helps characterize the manifestation of depression in a Hispanic population. The single item related to fatigue had the greatest variation across groups indicating it might be useful as a screening item. Inadequate evaluation of symptoms could lead to significant under identification of the disorder among Hispanics.

Cognitive reappraisal and the association between depressive symptoms and perceived social support among older adults

OBJECTIVES

There is an association between depression and diminished social support; indeed, interpersonal dysfunction is often a central feature of depression. The purpose of this study is to examine the role that an emotion regulation (ER) strategy, cognitive reappraisal, plays in influencing the association between depressive symptoms and perceived social support in older adults.

METHOD

Data for this cross-sectional study come from a community-based survey of older adults (60+, N = 910). We examined the effects of depressive symptoms and cognitive reappraisal on perceived social support. We then examined the potential moderating role of cognitive reappraisal on the association between depressive symptoms and perceived social support.

RESULTS

Depressive symptoms were associated with lower levels of perceived social support. Cognitive reappraisal was associated with higher levels of perceived social support. Cognitive reappraisal moderated the negative consequences of depressive symptoms on perceived social support. Whereas depressive symptoms had a negative effect on perceived social support, the negative effect was greater for those with lower levels of cognitive reappraisal compared to those with higher levels of cognitive reappraisal.

DISCUSSION

ER strategies may play a role in attenuating the negative consequences of depressive symptoms on social support in older age. It may be possible to help individuals maintain social support in later life, even in the face of mental health challenges, if they cultivate ER skills.

Quality of Life Impacts of Bright Light Treatment, Fluoxetine, and the Combination in Patients with Nonseasonal Major Depressive Disorder: A Randomized Clinical Trial

OBJECTIVE

Bright light therapy is increasingly recommended (alone or in combination with antidepressant medication) to treat symptoms of nonseasonal major depressive disorder (MDD). However, little is known about its impacts on quality of life (QoL), a holistic, patient-valued outcome.

METHODS

This study utilizes secondary outcome data from an 8-week randomized, controlled, double blind trial comparing light monotherapy (n = 32), fluoxetine monotherapy (n = 30), and the combination of these (n = 27) to placebo (n = 30). QoL was assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Treatment-related differences in QoL improvements were assessed using a repeated measures analysis of variance. The influence of potential predictors of QoL (demographic variables and change in depressive symptoms) were investigated via hierarchical linear regression.

RESULTS

Q-LES-Q-SF scores significantly improved across all treatment conditions; however, no significant differences were observed between treatment arms. QoL remained poor relative to community norms by the end of the trial period: Across conditions, 70.6% of participants had significantly impaired QoL at the 8-week assessment. Reduction in depressive scores was a significant predictor of improved QoL, with the final model accounting for 54% of variance in QoL change scores.

CONCLUSION

The findings of this study emphasize that improvement in QoL and reduction in depressive symptoms in MDD, while related, cannot be taken to be synonymous. Adjunctive therapies may be required to address unmet QoL needs in patients with MDD receiving antidepressant or light therapies. Further research is required to explore additional predictors of QoL in order to better refine treatments for MDD.

Neuromodulation for major depressive disorder: innovative measures to capture efficacy and outcomes

Major depressive disorder is a common and debilitating disorder. Although most patients with this disorder benefit from established treatments, a subset of patients have symptoms that remain treatment resistant. Novel treatment approaches, such as deep brain stimulation, are urgently needed for patients with treatment-resistant major depressive disorder. These novel treatments are currently being tested in clinical trials in which success hinges on how accurately and comprehensively the primary outcome measure captures the treatment effect. In this Personal View, we argue that current measures used to assess outcomes in neurosurgical trials of major depressive disorder might be missing clinically important treatment effects. A crucial problem of continuing to use suboptimal outcome measures is that true signals of efficacy might be missed, thereby disqualifying potentially effective treatments. We argue that a re-evaluation of how outcomes are measured in these trials is much overdue and describe several novel approaches that attempt to better capture meaningful change.

Social withdrawal in major depressive disorder: a case-control study of hikikomori in japan

BACKGROUND

Social withdrawal is a feature of a number of psychiatric disorders including major depressive disorder (MDD), yet research examining social withdrawal as a feature of MDD is rare.

METHODS

This was a retrospective case-control study. Participants (N = 67) were recruited through an outpatient clinic at an academic medical center in Japan. Major depressive disorder (MDD) and social withdrawal were established with the Structured Clinical Interview for DSM-IV Axis I Disorders and a semi-structured psychiatric interview, respectively. Participants also completed self-report measures.

RESULTS

We classified 24 participants as cases (MDD with social withdrawal) and 43 participants as controls (MDD without social withdrawal). Cases, on average, were more likely to have lower education level, prior episodes of depression, and higher suicidal ideation at baseline than controls. In unadjusted regression models, cases had significantly less social connection, less reward dependence, less self-directedness, and higher scores on scales of modern-type depression and hikikomori. In adjusted regression models, associations between social withdrawal and hikikomori (p<0.01) and reward dependence (p = 0.03) remained significant.

LIMITATIONS

The sample was limited in size and drawn from a single site.

CONCLUSIONS

In patients with MDD, social withdrawal may have subtle associations with clinical symptoms, social connection, and personality traits. Developing a better understanding of social withdrawal's phenotype in depression requires more in-depth examination.

Depression and prostate cancer: implications for urologists and oncologists

Many patients with prostate cancer experience severe levels of depression, which can negatively affect their treatment and disease course. Some prostate cancer treatments can increase the severity of a patient's depression, for example, by increasing anhedonia and erectile dysfunction. Depression is often thought of as a unitary phenomenon, but multiple subtypes can be distinguished. This variety of manifestations challenges the successful application of universal antidepressant treatment options and argues for a multi-symptom assessment process that considers a patient's disease burden and their particular form of depression. Inclusion of screening and detailed diagnosis of depression can be argued to be part of good practice, and clinicians are urged to consider when and how this might be accomplished within their urological practice.

Successfully treated patients with vortioxetine versus venlafaxine: a simplified cost-effectiveness analysis based on a head-to-head study in Asian patients with major depressive disorder

Objective: To compare the rates of successfully treated patients (STPs) with vortioxetine versus venlafaxine in major depressive disorder (MDD), using dual endpoints that combine improvement of mood symptoms with optimal tolerability or functional remission, and conduct a simplified cost-effectiveness analysis.Methods: The 8-week SOLUTION study (NCT01571453) assessed the efficacy and safety of vortioxetine (10 mg/day) versus venlafaxine XR (150 mg/day) in adult Asian patients with MDD. Rates were calculated post-hoc of STP Mood and Tolerability (≥50% reduction from baseline in Montgomery-Åsberg Depression Rating Scale [MADRS] total score and no treatment-emergent adverse events) and STP Mood and Functioning (≥50% reduction from baseline in MADRS total score and Sheehan Disability Scale total score ≤6). The incremental costs per STP were assessed using the 2018 pharmacy purchase prices for branded vortioxetine/branded venlafaxine in China as the base case.Results: STP Mood and Tolerability rates were 28.9% for vortioxetine and 19.9% for venlafaxine (p = .028); the corresponding STP Mood and Functioning rates were 28.0% and 23.5% (p = .281). Drug costs for the 8-week treatment period were CN¥1954 for vortioxetine and CN¥700 for venlafaxine. The incremental cost per STP for vortioxetine versus venlafaxine was CN¥13,938 for Mood and Tolerability and CN¥27,876 for Mood and Functioning.Conclusions: Higher rates of dual treatment success were seen with vortioxetine versus venlafaxine. Although vortioxetine was not dominant in the base case, the incremental cost per STP for vortioxetine versus venlafaxine were overall within acceptable ranges. These results support the benefits previously reported with vortioxetine versus other antidepressants in broad efficacy, tolerability profile and cost-effectiveness.

Evaluation of the effects of rTMS on self-reported quality of life and disability in treatment-resistant depression: A THREE-D study

INTRODUCTION

Although the antidepressant efficacy of rTMS is well documented, patient reported outcomes (PROs) with rTMS are poorly characterized. The aim of the current study is to assess short and long-term changes in self-reported quality of life and disability following a 6-week course of rTMS.

METHODS

We performed a secondary analysis of data from the multi-centre THREE-D trial of 10 Hz high-frequency (HF) rTMS (n = 192) vs. intermittent theta-burst stimulation (iTBS) (n = 193) of the left dorsolateral prefrontal cortex (DLPFC). We assessed changes in the Quality of Life Enjoyment and Satisfaction Questionnaire and Sheehan Disability Scale pre-treatment, at 1-week post-rTMS treatment (Acute Follow-up), and at 12-weeks post-treatment (Long-Term Follow-Up).

RESULTS

PROs significantly improved with rTMS. There were no differences in PROs between iTBS and HF left DLPFC rTMS at either the Acute or Long-Term Follow-Up. The magnitude of the change in effect sizes seen for the PROs were significantly greater in those who achieved greater resolution their depressive symptoms, with remitters demonstrating very large effect size improvements in PROs compared to small-to-medium effect sizes in non-remitters.

CONCLUSIONS

This study is the largest in the literature exploring at the effect of rTMS on PROs. rTMS yielded acute and sustained improvements in PROs. The improvements in PROs were strongly associated with the degree of resolution of depressive symptoms. The magnitude of the change in remitters was comparable to those reported with ECT. The goal of a course of rTMS should be for full remission of depressive symptoms in order to achieve optimal functional outcomes.

Repetitive Transcranial Magnetic Stimulation Combined with Antidepressants for the First Episode of Major Depressive Disorder

Objectives

The aims of this study were to systematically review the efficacy, acceptability, and tolerability of repetitive transcranial magnetic stimulation (rTMS) combined with antidepressants in the treatment of the first major depressive disorder (MDD) episode.

Materials and Methods

The primary efficacious outcome was the pooled mean-endpoint scores of the Hamilton Depression Rating Scale (HAMD). Rates of response, remission rate, overall discontinuation and discontinuation due to adverse events were also evaluated. Search in the Scopus, PubMed, CINAHL, and Cochrane Controlled Trials Register databases for interesting outcomes was carried out in March 2018.

Results

A total of 108 randomized patients of two randomized controlled trials were included in this study. The pooled mean- endpoint scores of the HAMD in one, two, and four weeks for rTMS plus antidepressants (citalopram or paroxetine) were greater than that of sham plus the antidepressants. The pooled rates of overall discontinuation and discontinuation rates due to adverse events were not different between the two groups.

Conclusion

According to a piece of limited evidence, the high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) could accelerate the antidepressant effect of SSRIs in young patients with a first-episode major depressive disorder. However, the acceptability and tolerability of HF-rTMS in the treatment of such patients are no better than an antidepressant alone. However, further well-defined and large sample-size studies of HF-rTMS combined with an antidepressant in MDD should be carried out to warrant these results.

Effectiveness of electroconvulsive therapy on treatment-resistant depressive disorder: A population-based mirror-image study

The clinical effects of electroconvulsive therapy (ECT) in treatment-resistant depressive disorders need to be systemically examined in representative samples. This study aimed to examine whether ECT reduced re-hospitalization within one year after discharge. The authors used the Psychiatric Inpatients Medical Claim Dataset, a subset of a total population health claims database from Taiwan, to include 784 inpatients with treatment-resistant depressive disorders screened for ECT during hospitalization between 2001 and 2011. The same number of comparison subjects was selected by frequency matching on the demographic and clinical characteristics. Using a mirror-image comparison design, we compared group differences in re-hospitalization rate, number of hospital days, number of emergency department visits, and direct medical costs during the 1-year pre- and post-ECT periods. The modifying effects of patients' characteristics on these outcomes were also explored. The results showed that ECT was associated with a significant decrease in the rate of hospitalizations and emergency department visits over the 1-year follow-up period. However, there were no significant difference in the reduced rate of hospitalizations between ECT and comparison group. Demographic and clinical characteristic had no modifying effect on the odds of psychiatric hospitalization. In conclusions, ECT could reduce the rate of hospitalization and number of emergency department visits in patients with treatment-resistant depressive disorders. However, the study results might be biased by the inherent deficits of mirror-image design.

A randomized, double-blind, 6-week prospective pilot study on the efficacy and safety of dose escalation in non-remitters in comparison to those of the standard dose of escitalopram for major depressive disorder

BACKGROUND

Escalating doses of selective serotonin reuptake inhibitors are often used to treat patients with a suboptimal response to the standard dose. This study assessed the efficacy and safety of dose escalation of escitalopram, up to 30 mg, in non-remitters with major depressive disorder (MDD) after treatment with the standard dose.

METHOD

We recruited 98 patients with MDD (aged 18-65 years). After 4 weeks of open-label treatment with 10-20 mg of escitalopram per day, non-remitters [Montgomery-Åsberg Depression Rating Scale (MADRS) score > 10] were randomized 1:1 for double-blind treatment with either escitalopram (30 mg per day) or escitalopram (20 mg per day) plus placebo for 6 weeks. The primary efficacy outcome was a change in the total MADRS score.

RESULTS

After 4 weeks of open-label treatment, 12 patients achieved remission, and 36 dropped out, leaving 50 non-remitters, of whom 44 (88%) completed the double-blind study. The primary outcome measure, the least-squares mean (standard error) change in the total MADRS score at week 6 was significantly different (p = 0.046) between the groups [-8.0 (1.2) in the placebo dose-escalation and -11.8 (1.2) in the escitalopram dose-escalation]. The dose escalation of escitalopram was well tolerated. However, the response and remission rates and quality of life showed no significant differences.

LIMITATIONS

Small sample size and short follow-up period CONCLUSION: This study suggests that dose escalation of escitalopram up to 30 mg per day may be beneficial for the treatment of depressive symptoms in non-remitters after standard (10-20 mg/day) treatment.

Patients as Agents in Behavioral Health Research and Service Provision: Recommendations to Support the Learning Health System

Authentic inclusion and engagement of behavioral health patients in their care delivery and in the process of scientific discovery are often challenged in the health care system. Consequently, there is a growing need to engage with and better serve the needs of behavioral health patients, particularly by leveraging health information technologies. In this work, we present rationale and strategies for improving patient engagement in this population in research and clinical care. First, we describe the potential for creating meaningful patient-investigator partnerships in behavioral health research to allow for cocreation of knowledge with patients. Second, in the context of behavioral health services, we explore the utility of sharing clinical notes to promote patients' agency in care delivery. Both lines of inquiry are centered in a Learning Health System model for behavioral health, where patients are agents in enhancing the therapeutic alliance and advancing the process of knowledge generation. Recommendations include genuinely democratizing the health care system and biomedical research enterprise through patient-centered information technologies such as patient portals. In research and technology development, we recommend seeking and tailoring behavioral health patients' involvement to their abilities, promoting patient input in data analysis plans, evaluating research and informatics initiatives for patients and clinicians, and sharing success and research findings with patients. In clinical practice, we recommend encouraging patients to read behavioral health notes on portals, engaging in proactive communication regarding note content, assessing outcomes including stress and anxiety in response to note content, and working with technology providers to support note-sharing governance and deployment.

Measurement of patient-reported outcomes. 1: The search for the Holy Grail

Patient-reported outcome measures (PROMs) are used to collect information directly from patients. They may cover several different types of outcomes ranging from symptoms, functioning, utility, satisfaction, through to quality-of-life (QoL). They generally consist of self-completed questionnaires that can be administered by means of hard copies or in a range of electronic formats. PROMs vary considerably in terms of the constructs they assess, the care with which they are developed, and their scientific quality. However, none of the PROMs available approach the quality of measurement achieved by measures/instruments used in physics. PROs are examples of latent variables. These are not directly observable, but can be inferred from, for example, responses to a questionnaire. The only measure of a latent variable that approaches the quality of measurement achieved by the physical sciences is the Lexile Framework for Reading. This framework is based on a construct theory that grew out of an analysis of several available reading measures. A specification equation was generated that was able to link the construct theory to scores obtained with the Lexile measure. A fundamental requirement of this quality of measurement is that the data collected with the model fit Rasch Measurement Theory (RMT). It is argued that PROM developers should aspire to match this level of measurement sophistication if their instruments are to provide valid insights into the impacts of disease and its treatment.

Irritability and Its Clinical Utility in Major Depressive Disorder: Prediction of Individual-Level Acute-Phase Outcomes Using Early Changes in Irritability and Depression Severity

OBJECTIVE

The authors evaluated improvement in irritability with antidepressant treatment and its prognostic utility in treatment-seeking adult outpatients with major depressive disorder.

METHODS

Mixed-model analyses were used to assess changes in irritability (as measured with the five-item irritability domain of the Concise Associated Symptom Tracking [CAST-IRR] scale) from baseline to week 4 after controlling for depression severity (as measured with the 16-item Quick Inventory of Depressive Symptomatology-Clinician Rated [QIDS-C]) in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial (N=664). An interactive calculator for remission (QIDS-C score ≤5) and no meaningful benefit (<30% reduction in QIDS-C score from baseline) at week 8 was developed with logistic regression analyses in the CO-MED trial using participants with complete data (N=431) and independently replicated in the Suicide Assessment and Methodology Study (SAMS) (N=163).

RESULTS

In the CO-MED trial, irritability was significantly reduced (effect size=1.06) from baseline to week 4, and this reduction remained significant after adjusting for QIDS-C change (adjusted effect size=0.36). A one-standard-deviation greater reduction in CAST-IRR score from baseline to week 4 predicted a 1.73 times higher likelihood of remission and a 0.72 times lower likelihood of no meaningful benefit at week 8, independent of baseline QIDS-C and CAST-IRR scores and reduction in QIDS-C score from baseline to week 4. The model estimates for remission (area under the curve [AUC]=0.79) and no meaningful benefit (AUC=0.76) in the CO-MED trial were used to predict remission (AUC=0.80) and no meaningful benefit (AUC=0.84) in SAMS and to develop an interactive calculator.

CONCLUSIONS

Irritability is an important symptom domain of major depressive disorder that is not fully reflected in depressive symptom severity measures. Early reductions in irritability, when combined with changes in depressive symptom severity, provide a robust estimate of likelihood of remission or no meaningful benefit in outpatients with major depression.

Clinical application of antidepressant pharmacogenetics: Considerations for the design of future studies

A frustrating inertia has affected the development of clinical applications of antidepressant pharmacogenetics and personalized treatments of depression are still lacking 20 years after the first findings. Candidate gene studies provided replicated findings for some polymorphisms, but each of them shows at best a small effect on antidepressant efficacy and the cumulative effect of different polymorphisms is unclear. Further, no candidate was immune by at least some negative studies. These considerations give rise to some concerns about the clinical benefits of currently available pharmacogenetic tests since they are based on the results of candidate gene studies. Clinical guidelines in fact suggest that only polymorphisms that alter cytochrome 2D6 or 2C19 enzymatic activity probably provide useful clinical indications, while variants in genes involved in antidepressant pharmacodynamics have no recommended clinical applications. The present review discusses possible strategies to facilitate the identification of genetic biomarkers with clinical usefulness in guiding antidepressant treatments. These include analysis methods for the study of the polygenic/omnigenic nature of antidepressant response, the prioritization of polymorphisms on the basis of functional considerations, the incorporation of clinical-demographic predictors in pharmacogenetic studies (e.g. mixed polygenic and clinical risk scores), the application of methodological improvements to the design of future studies in order to maximize the comparability of results and improve power.

Improvements in Health-Related Quality of Life With Electroconvulsive Therapy: A Meta-analysis

INTRODUCTION

Although the antidepressant efficacy of ECT is well documented, patient-reported outcomes after this treatment are less well characterized. The aims of the current meta-analysis are to quantify the impact of an acute course of ECT on health-related quality of life (HRQoL) and to identify related moderators, specifically post-ECT depressive symptom remission and patient age.

METHODS

We searched PubMed, PsycINFO, and Web of Science databases for randomized and nonrandomized studies that report on changes in HRQoL measures after an acute course of ECT. Only studies that used the Medical Outcomes Study Short Form 36 (SF-36) instrument were included. A random effects model using the Hedges' g effect size was used in calculating the pre-post ECT outcomes on all 8 SF-36 subscales and the SF-36 total scores including the physical and mental composite scores. Subgroup analyses were conducted using remission status and age as moderators.

RESULTS

Four studies contributed to this analysis. Significant improvements across all subscales of the SF-36 were observed. Large and very large effect sizes were present for both the SF-36 physical component score (PCS) and mental health component score (MCS), with the change in MCS being statistically superior to the PCS (MCS, Hedges' g = 1.28; 95% confidence interval, 1.15-1.42; PCS, Hedges' g = 0.97; 95% confidence interval, 0.86-1.07). Medium, large, and very large effect sizes were observed for SF-36 subscales scores. Post-ECT depression remission status was related to HRQoL improvement, with statistically significant differences present between remitters and nonremitters for PCS, MCS, and most SF-36 subscale scores. No significant differences were observed in improvement in HRQoL with ECT based on patient age.

CONCLUSIONS

An acute course of ECT for depressive symptoms produces medium to very large effect size improvements in HRQoL across multiple components and subscales measured by the SF-36. The magnitude of the effects reported by ECT patients is greater than those that have been reported in other open-label studies of brain stimulation techniques. This study confirms that ECT plays a vital role in the treatment of the most severely ill patients with depressive disorders.

Effects of adjunctive N-acetylcysteine on depressive symptoms: Modulation by baseline high-sensitivity C-reactive protein

Outcomes in a RCTs of 12 weeks of theclinical efficacy of N-acetylcysteine (NAC) as an adjunctive treatment on depression and anxiety symptoms and its effects on high-sensitivity C-reactive protein (hs-CRP) levels. A wide array of measures were made. The 17-item version of the Hamilton Depression Rating Scale (HDRS17); the Hamilton Anxiety Rating Scale (HAM-A); Sheehan Disability Scale; Quality of Life; Clinical Global Impression (CGI); anthropometrics measures; and vital signs and biochemical laboratory. There were no significant differences among the groups regarding demographic, clinical features, use of medication, metabolic syndrome and comorbidities. From baseline to week 12, individuals receiving NAC, versus placebo, had a statistically significant reduction in depressive symptoms on HDRS₁₇ (p < 0.01) and anxiety symptoms on HAM-A (p = 0.04), but only for individuals with levels of hs-CRP > 3 mg/L at baseline. Individuals receiving NAC with baseline levels of hs-CRP > 3 mg/L, had more significant reduction in uric acid levels compared to individuals with baseline levels of hs-CRP ≤ 3 mg/L on week 12. Participants receiving placebogained significantly more weight during the 12 weeks for baseline levels of hs-CRP ≤ 3 mg/L and hs-CRP > 3 mg/L, and individuals receiving NAC in both groups did not have significant weight change during the 12 weeks. No individuals were withdrawn from the study because of adverse event. NAC group exhibited significantly greater reduction on hs-CRP levels than placebo group from baseline to week 12.

TRIAL REGISTRATION

clinicaltrials.gov Identifier; NCT02252341.

Abstinence and reduced frequency of use are associated with improvements in quality of life among treatment-seekers with cannabis use disorder

BACKGROUND AND OBJECTIVE

Many patients with cannabis use disorder (CUD) do not achieve or do not have abstinence as a goal of treatment, rather they reduce their use. Assessing outcome measures as they relate to functioning and reductions in cannabis use is an important area of study. Quality of life (QoL) shows promise as one such measure. Past studies have demonstrated gender differences in QoL and CUD. We aim to assess (1) the relationship between cannabis use and QoL and (2) gender effects in an outpatient medication treatment study for CUD.

METHODS

Data from an 11-weeks, double-blind, placebo-controlled trial of lofexidine and dronabinol for CUD (n = 62) was analyzed. Pearson's correlations between baseline QoL as measured with the Quality of Life, Enjoyment, and Satisfaction Questionnaire-Short Form (QLES-Q-SF) and cannabis use assessed with modified timeline follow-back (TLFB) were examined. Multiple linear regression models of cannabis use on end of study QLES-Q-SF were analyzed, while adjusting for baseline QLES-Q-SF, study arm, and gender. Moderation effects with gender were also tested.

RESULTS

No significant association between baseline cannabis use and QoL was found. End of study abstinence (F_{1,47   =}  8.34, p = .006) and reduced proportion of using days (F_1,47  = 9.48, p = .004) were each significantly associated with end of study QoL. Reduction in grams (F_1,27  = 0.25, p = .62) was not associated with QoL at end of study. Gender was not a significant moderator.

DISCUSSION AND CONCLUSIONS

Abstinence and lower frequency of use are associated with higher QoL, regardless of gender.

SCIENTIFIC SIGNIFICANCE

This is the first time QoL has been demonstrated to change over the course of CUD medication treatment. QoL is an important outcome in CUD treatment.

TRIAL REGISTRATION

NCT01020019. (Am J Addict 2018;27:101-107).

Escitalopram vs duloxetine in acute treatment of major depressive disorder: meta-analysis and systematic review

BACKGROUND

Previous evidence indicated that efficacy of escitalopram (Esc) and duloxetine (Dul) was comparable in the treatment of major depressive disorder (MDD). Since such studies had small sample sizes, this study purposefully applied a systematic review to determine the efficacy, acceptability, and tolerability those antidepressants in treatment of MDD.

PARTICIPANTS AND METHODS

The following primary databases were searched in July 2017: Scopus, PubMed, CINAHL, and Cochrane Controlled Trials Register. Any randomized controlled trials (RCTs) of Esc comparison with Dul in the treatment of MDD were included in this review. The primary efficacy of outcome was the pooled mean-changed scores of the rating scales for the standardized rating scales for depression.

RESULTS

A total of 1,120 randomized subjects from 3 RCTs were collected for synthesis in the present meta-analysis. The mean-changed scores of the Hamilton Depression Rating Scale (HAMD) and Clinical Global Impression - Severity, overall response rate by the HAMD, and remission rate by the HAMD and Montgomery-Asberg Depression Rating Scale (MADRS) in the Esc- and Dul-treated groups showed no significant differences. However, the mean-changed score of the MARDS, mean-end scores of Clinical Global Impression - Improvement, and overall response by the MADRS in the Esc-treated group were greater than that of the Dul-treated group. Although the overall discontinuation rate had no significant differences between the 2 groups, the discontinuation rate due to adverse events in the Esc-treated group was greater than that of the Dul-treated group.

LIMITATIONS

This review had limited eligible studies.

CONCLUSION

This review indicated the efficacy in the acute treatment of Esc vs Dul varied relying on measurements across the studies. However, the tolerability of Esc was superior to Dul in acute MDD treatment. Therefore, selection between the 2 antidepressants may depend on the tolerability of MDD patients. Due to limited included studies in this review, more large-scale and well-defined RCTs in such patients should be carried out to determine these outcomes.

ECT Has Greater Efficacy Than Fluoxetine in Alleviating the Burden of Illness for Patients with Major Depressive Disorder: A Taiwanese Pooled Analysis

BACKGROUND

The burden of major depressive disorder includes suffering due to symptom severity, functional impairment, and quality of life deficits. The aim of this study was to compare the differences between electroconvulsive therapy and pharmacotherapy in reducing such burdens.

METHODS

This was a pooled analysis study including 2 open-label trials for major depressive disorder inpatients receiving either standard bitemporal and modified electroconvulsive therapy with a maximum of 12 sessions or 20 mg/d of fluoxetine for 6 weeks. Symptom severity, functioning, and quality of life were assessed using the 17-item Hamilton Rating Scale for Depression, the Modified Work and Social Adjustment Scale, and SF-36. Side effects following treatment, including subjective memory impairment, nausea/vomiting, and headache, were recorded. The differences between these 2 groups in 17-item Hamilton Rating Scale for Depression, Modified Work and Social Adjustment Scale, quality of life, side effects, and time to response (at least a 50% reduction of 17-item Hamilton Rating Scale for Depression) and remission (17-item Hamilton Rating Scale for Depression ≤7) following treatment were analyzed.

RESULTS

Electroconvulsive therapy (n=116) showed a significantly greater reduction in 17-item Hamilton Rating Scale for Depression, Modified Work and Social Adjustment Scale, and quality of life deficits and had significantly shorter time to response/remission than fluoxetine (n=126). However, the electroconvulsive therapy group was more likely to experience subjective memory impairment and headache.

CONCLUSIONS

Compared with fluoxetine, electroconvulsive therapy was more effective in alleviating the burden of major depressive disorder and had a substantially increased speed of response/remission in the acute phase. Increased education and information about electroconvulsive therapy for clinicians, patients, and their families and the general public is warranted.

Efficacy of a Maternal Depression Prevention Strategy in Head Start: A Randomized Clinical Trial

IMPORTANCE

Low-income and minority mothers experience a disproportionate incidence of depression and lack access to treatment services. Development of prevention strategies in accessible community-based venues is a potentially important public health strategy.

OBJECTIVE

To determine the efficacy of a depression prevention strategy embedded in Head Start.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was performed from February 15, 2011, through May 9, 2016, at 6 Head Start agencies serving families at or below the federal poverty level. Participants included mothers with depressed mood, anhedonia, or depression history but who were not in a current major depressive episode. Participants were followed up for 12 months with masked outcome assessments. Final follow-up was completed on May 9, 2016.

INTERVENTIONS

Participants were randomized to a problem-solving education (PSE) intervention (n = 111) or usual Head Start services (n = 119).

MAIN OUTCOMES AND MEASURES

Primary outcomes were problem-solving skills and depressive symptoms. To capture the chronicity and intensity of symptoms, the Quick Inventory of Depressive Symptoms was administered bimonthly, and rates of clinically significant symptom elevations were compared across groups. Secondarily, the presence of a major depressive episode was assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

Among the 230 participants, 152 (66.1%) were Hispanic, with a mean (SD) age of 31.4 (7.3) years. An intention-to-treat analysis among 223 participants contributing follow-up data found no differences in problem-solving skills across groups. The mean (SD) number of depressive symptom elevations among the PSE participants was 0.84 (1.39) compared with 1.12 (1.47) among the usual service participants (adjusted incident rate ratio [aIRR], 0.60; 95% CI, 0.41-0.90). In analyses stratified according to baseline depressive symptoms, PSE exerted a preventive effect among those with lower-level baseline symptoms, with a mean (SD) of 0.39 (0.84) elevations among PSE participants compared with 0.88 (1.37) among usual service participants (aIRR, 0.39; 95% CI, 0.21-0.75). However, no difference was observed among those with higher-level baseline symptoms (mean [SD] elevations, 2.06 [1.92] for PSE and 2.00 [1.91] for usual service; aIRR, 1.10; 95% CI, 0.67-1.80). Analysis of symptom scores followed the same pattern, with an adjusted mean reduction of 1.33 (95% CI, 0.36-2.29) among participants with lower-level baseline symptoms.

CONCLUSIONS AND RELEVANCE

The PSE intervention is efficacious in preventing depressive symptom episodes and performs optimally among those with initial low-level symptoms. Additional effectiveness studies in Head Start are necessary to develop meaningful public health programs.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01298804.

Transdiagnostic Clinical Global Impression Scoring for Routine Clinical Settings

Although there is great interest in the improving the ability to track patients’ change over time in routine clinical care settings, no standardized transdiagnostic measure is currently available for busy clinicians to apply. The Clinical Global Impression (CGI) scales are simple measures widely used as outcomes in psychiatric clinical trials. However, the CGI suffers from poorly defined scoring anchors. Efforts to improve the anchors by enhancing the anchor descriptions have proven useful but are limited by being disease-specific, thereby acting as a barrier to the routine clinical adoption of the CGI. To inform the development of more broadly applicable CGI scoring anchors, we surveyed 24 clinical trial investigators, asking them to rank-order seven elements that inform their CGI-Severity (CGI-S) scoring. Symptom severity emerged as the most important element in determining CGI-S scores; the functional status of the patient emerged as a second element. Less importance was given to self-report symptom scores, staff observations, or side effects. Relative rankings of the elements’ importance did not differ by investigators’ experience nor time usually spent with patients. We integrated these results with published illness-specific CGI anchors to develop the Transdiagnostic CGI (T-CGI), which employs standardized scoring anchors applicable across psychiatric illnesses. Pending validity and reliability evaluations, the T-CGI may prove well-suited for inclusion in routine clinical settings and for incorporation into electronic medical records as a simple and useful measure of treatment efficacy.

Research Recommendations for Improving Measurement of Treatment Effectiveness in Depression

Background: Despite the steadily escalating psychological and economic burden of depression, there is a lack of evidence for the effectiveness of available interventions on functioning areas beyond symptomatology. Therefore, the main objective of this study was to give an insight into the current measurement of treatment effectiveness in depression and to provide recommendations for its improvement.

Materials and Methods: The study was based on a multi-informant approach, comparing data from a systematic literature review, an expert survey with representatives from clinical practice (130), and qualitative interviews with patients (11) experiencing depression.

Results: Current literature places emphasis on symptomatic outcomes and neglects other domains of functioning, whereas clinicians and depressed patients highlight the importance of both. Interpersonal relationships, recreation and daily activities, communication, social participation, work difficulties were identified as being crucial for recovery. Personal factors, neglected by the literature, such as self-efficacy were introduced by experts and patients. Furthermore, clinicians and patients identified a number of differences regarding the areas improved by psychotherapeutic or pharmacological interventions that were not addressed by the pertinent literature.

Conclusion: Creation of a new cross-nationally applicable measure of psychosocial functioning, broader remission criteria, report of domain-specific information, and a personalized approach in treatment decision-making are the first crucial steps needed for the improvement of the measurement of treatment effectiveness in depression. A better measurement will facilitate the clinical decision making and answer the escalating burden of depression.

The efficacy of psychotherapy, pharmacotherapy and their combination on functioning and quality of life in depression: a meta-analysis

BACKGROUND

There is growing recognition of the importance of both functioning and quality of life (QoL) outcomes in the treatment of depressive disorders, but the meta-analytic evidence is scarce. The objective of this meta-analysis of randomized controlled trials (RCTs) was to determine the absolute and relative effects of psychotherapy, pharmacotherapy and their combination on functioning and QoL in patients with depression.

METHOD

One hundred and fifty-three outcome trials involving 29 879 participants with depressive disorders were identified through database searches in Pubmed, PsycINFO and the Cochrane Central Register of Controlled Trials.

RESULTS

Compared to control conditions, psychotherapy and pharmacotherapy yielded small to moderate effect sizes for functioning and QoL, ranging from g = 0.31 to g = 0.43. When compared directly, initial analysis yielded no evidence that one of them was superior. After adjusting for publication bias, psychotherapy was more efficacious than pharmacotherapy (g = 0.21) for QoL. The combination of psychotherapy and medication performed significantly better for both outcomes compared to each treatment alone yielding small effect sizes (g = 0.32 to g = 0.39). Both interventions improved depression symptom severity more than functioning and QoL.

CONCLUSION

Despite the small number of comparative trials for some of the analyses, this study reveals that combined treatment is superior, but psychotherapy and pharmacotherapy alone are also efficacious for improving functioning and QoL. The overall relatively modest effects suggest that future tailoring of therapies could be warranted to better meet the needs of individuals with functioning and QoL problems.

Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.

Daily activity level improvement with antidepressant medications predicts long-term clinical outcomes in outpatients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) significantly impacts performance of both work- and nonwork-related routine daily activities. We have shown that work productivity is significantly impaired in employed MDD patients, but the extent of impairments in nonwork-related routine activities and its association with antidepressant treatment outcomes has not been established.

MATERIALS AND METHODS

Activity impairment was measured using the sixth item of Work Productivity and Activity Impairment Scale in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial (n=665). Published norms were used to define activity impairment levels. The relationship between activity impairment and baseline sociodemographic and clinical characteristics was evaluated along with changes in activity impairment and its relationship with other clinical outcomes such as symptom severity, function, and side effect burden. Remission status at 3 and 7 months was predicted based on week 6 activity impairment level.

RESULTS

Higher psychosocial and cognitive impairments and greater number of comorbid medical conditions were associated with greater activity impairment at baseline. Proportion of participants with severe activity impairment declined from 47.6% at baseline to 18.7% at 3 months, while mean activity impairment decreased from 57.1 at baseline to 32.8 at 3 months. During course of treatment, levels of activity impairment correlated most strongly with psychosocial function among measures of symptom severity, function, quality of life, and side effect burden. No or minimal activity impairment at week 6 was associated with two to three times higher rates of remission at 3 and 7 months as compared to moderate or severe activity impairment levels even after controlling for remission status at week 6 and select baseline variables.

CONCLUSION

Depressed patients have high levels of nonwork-related activity impairment at baseline that improves significantly with treatment and independently predicts long-term clinical outcomes. Brief systematic assessment of activity impairment during the course of antidepressant treatment can help inform clinical decision-making.

Early Improvement in Psychosocial Function Predicts Longer-Term Symptomatic Remission in Depressed Patients

The goal of this study was to evaluate the relationship between early change in psychosocial function independent of depression severity and longer-term symptomatic remission. Participants of Combining Medications to Enhance Depression Outcomes trial were randomly selected for model selection (n = 334) and validation (n = 331). Changes in psychosocial function (Work and Social Adjustment Scale, WSAS) from baseline to week 6 were assessed and two data-driven sub-groups of WSAS change were identified in the randomly selected model selection half. Results of analyses to predict symptomatic remission at 3 and 7 months were validated for these sub-groups in the second half (validation sample). From baseline to week 6, psychosocial function improved significantly even after adjusting for depression severity at each visit and select baseline variables (age, gender, race, ethnicity, education, income, employment, depression onset before age 18, anxious features, and suicidal ideation), treatment-arm, and WSAS score. The WSAS change patterns identified two (early improvement and gradual change) subgroups. After adjusting for baseline variables and remission status at week 6, participants with early improvement in the second half (validation sample) had greater remission rates than those with gradual change at both 3 (3.3 times) and 7 months (2.3 times) following acute treatment initiation. In conclusion, early improvement in psychosocial function provides a clinically meaningful prediction of longer-term symptomatic remission, independent of depression symptom severity.

Early Improvement in Work Productivity Predicts Future Clinical Course in Depressed Outpatients: Findings From the CO-MED Trial

OBJECTIVE

Depression symptom severity, the most commonly studied outcome in antidepressant treatment trials, accounts for only a small portion of burden related to major depression. While lost work productivity is the biggest contributor to depression's economic burden, few studies have systematically evaluated the independent effect of treatment on work productivity and the relationship between changes in work productivity and longer-term clinical course.

METHOD

Work productivity was measured repeatedly by the Work Productivity and Activity Impairment self-report questionnaire in 331 employed participants with major depression enrolled in the Combining Medications to Enhance Depression Outcomes trial. Trajectories of change in work productivity during the first 6 weeks of treatment were identified and used to predict remission at 3 and 7 months.

RESULTS

Participants reported reduced absence from work and increased work productivity with antidepressant treatment even after controlling for changes in depression severity. Three distinct trajectories of changes in work productivity were identified: 1) robust early improvement (24%), 2) minimal change (49%), and 3) high-impairment slight reduction (27%). Compared with other participants, those with robust improvement had 3-5 times higher remission rates at 3 months and 2-5 times higher remission rates at 7 months, even after controlling for select baseline variables and remission status at week 6.

CONCLUSIONS

In this secondary analysis, self-reported work productivity improved in depressed patients with antidepressant treatment even after accounting for depressive symptom reduction. Early improvement in work productivity is associated with much higher remission rates after 3 and 7 months of treatment.

Early normalization of Quality of Life predicts later remission in depression: Findings from the CO-MED trial

BACKGROUND

Although normal Quality of Life (QoL) is the outcome desired by patients, it is unclear if QoL changes early in course of antidepressant treatments are independent of depression severity, and can predict subsequent remission.

METHODS

The Quality of Life Inventory was obtained repeatedly in the Combining Medications to Enhance Depression Outcomes trial. Mixed model analyses assessed QoL change. Using population-based norms, participants were grouped as very low, low, or normal QoL at week 4, and association with remission was evaluated.

RESULTS

Overall baseline to week 4 QoL improved significantly (p=0.0015) even after controlling for change in depression severity and baseline variables (gender, age, education, race, ethnicity, income, employment status, anxious features, depression onset before age 18, suicidal ideations, and treatment-arm). At week 4, participants with low and normal QoL had higher unadjusted odds ratio (OR) for remission at 3 months (low QoL OR=2.36, 95% confidence interval (CI)=1.25,4.44; normal QoL OR=2.59, 95% CI=1.53,4.39) and 7 months (low QoL OR=2.07, 95% CI=1.00,4.31; normal QoL OR=3.98, 95% CI=2.06,7.69) compared to those with very low QoL. Remission rates, adjusted for baseline variables, were higher only for participants with normal QoL (3 months OR=2.83, 95% CI=1.42,5.68; 7 months OR=6.10, 95% CI=2.40,15.63).

LIMITATIONS

Secondary analysis, short period of assessment for QoL change, remission instead of functional recovery as long-term outcome.

CONCLUSION

Quality of life improves early, independent of depression severity. Normal QoL at week 4 is associated with 2-6 times higher remission rates. Findings support QoL beyond symptomatic change as a potential mediator of remission.

Which Are the Most Burdensome Functioning Areas in Depression? A Cross-National Study

BACKGROUND

The study aimed to identify the most burdensome functioning domains in depression and their differential impact on the quality of life (QoL) of individuals from nine countries in Asia, Africa, Europe, and Latin America.

MATERIALS AND METHODS

Data from two multi-country projects-the World Health Organization's Study on Global Ageing and Adult Health (SAGE) and the Collaborative Research on Ageing in Europe (COURAGE)-were analyzed. Eight functioning domains (pain, mobility, self-care, cognition, interpersonal activities, domestic life, and work, sleep and energy, and affect) and QoL were assessed in 4051 individuals with depression.

RESULTS

The analyses of the pooled sample showed that affect (ß = -0.21, p < 0.001), domestic life and work (ß = -0.16, p < 0.001) and interpersonal activities (ß = -0.15, p < 0.001) were the most affected functioning domains. When the analysis was stratified by gender, women showed similar patterns to the total sample, whereas mobility, self-care, cognition and pain were not significant amongst men. The cross-national analysis revealed that difficulties in affect and interpersonal activities were common across countries, whereas the rest of the domains showed country variability. In addition, being a woman (ß = -0.05), being older (ß = 0.07), being married (ß = 0.05), not having a comorbid condition (ß = -0.03) and having a higher education (ß = 0.04) were all factors associated with higher levels of QoL.

CONCLUSION

There was a variation in the level of decrements in different functioning domains across countries. This is in line with the growing evidence that reporting functioning sum-scores obscures potential differences among people. Functioning tools should capture the distinctiveness among individuals in order to provide tailored responses.

Calibrating well-being, quality of life and common mental disorder items: psychometric epidemiology in public mental health research

BACKGROUND

The assessment of 'general health and well-being' in public mental health research stimulates debates around relative merits of questionnaire instruments and their items. Little evidence regarding alignment or differential advantages of instruments or items has appeared to date.

AIMS

Population-based psychometric study of items employed in public mental health narratives.

METHOD

Multidimensional item response theory was applied to General Health Questionnaire (GHQ-12), Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and EQ-5D items (Health Survey for England, 2010-2012; n = 19 290).

RESULTS

A bifactor model provided the best account of the data and showed that the GHQ-12 and WEMWBS items assess mainly the same construct. Only one item of the EQ-5D showed relevant overlap with this dimension (anxiety/depression). Findings were corroborated by comparisons with alternative models and cross-validation analyses.

CONCLUSIONS

The consequences of this lack of differentiation (GHQ-12 v. WEMWBS) for mental health and well-being narratives deserves discussion to enrich debates on priorities in public mental health and its assessment.

Social functioning in major depressive disorder

Depression is associated with social risk factors, social impairments and poor social functioning. This paper gives an overview of these social aspects using the NIMH Research and Domain Criteria 'Systems for Social Processes' as a framework. In particular, it describes the bio-psycho-social interplay regarding impaired affiliation and attachment (social anhedonia, hyper-sensitivity to social rejection, competition avoidance, increased altruistic punishment), impaired social communication (impaired emotion recognition, diminished cooperativeness), impaired social perception (reduced empathy, theory-of-mind deficits) and their impact on social networks and the use of social media. It describes these dysfunctional social processes at the behavioural, neuroanatomical, neurochemical and genetic levels, and with respect to animal models of social stress. We discuss the diagnostic specificity of these social deficit constructs for depression and in relation to depression severity. Since social factors are importantly involved in the pathogenesis and the consequences of depression, such research will likely contribute to better diagnostic assessments and concepts, treatments and preventative strategies both at the diagnostic and transdiagnostic level.