Achieving remission with venlafaxine and fluoxetine in major depression: its relationship to anxiety symptoms

Ketamine causes poor maternal care in rats with postpartum depression and leads to few behavioral and neurochemical alterations on male offspring

Ketamine is an anesthetic drug that also has antidepressant properties, with quick action. Despite the great number of studies showing its effectiveness as a treatment for major depression, there is little information about its effects on postpartum depression, as pharmacological treatments bring risks to the health of both mother and child. Thus, this study aimed to evaluate the effects of prolonged treatment with subanesthetic doses of ketamine in a rat model of postpartum depression. Female dams were induced to postpartum depression by the maternal separation model from lactating day (LD) 2-12. They were divided into four groups: one control and three experimental groups, which were treated with different doses of ketamine (5, 10 or 20 mg/kg) from LD 2-21 i.p. Maternal studies were conducted from LD5 to LD21 and the offspring studies from postnatal day 2 through 90. Ketamine causes poor maternal care, with few neurochemical alterations. However, the highest dose used in this study had an antidepressant effect. Regarding the male offspring, indirect exposure to ketamine through breast milk caused few behavioral changes during infancy, but they were not permanent, as they faded in adulthood. Nevertheless, this exposure was able to cause alterations in their monoaminergic neurotransmission systems that were found in both infancy and adulthood periods.

Effects of Anxious Depression on Antidepressant Treatment Response

Anxious depression represents a subtype of major depressive disorder and is associated with increased suicidality, severity, chronicity and lower treatment response. Only a few studies have investigated the differences between anxious depressed (aMDD) and non-anxious depressed (naMDD) patients regarding treatment dosage, serum-concentration and drug-specific treatment response. In our naturalistic and prospective study, we investigated whether the effectiveness of therapy including antidepressants (SSRI, SNRI, NaSSA, tricyclics and combinations) in aMDD patients differs significantly from that in naMDD patients. In a sample of 346 patients, we calculated the anxiety somatization factor (ASF) and defined treatment response as a reduction (≥50%) in the Hamilton Depression Rating Scale (HDRS)-21 score after 7 weeks of pharmacological treatment. We did not observe an association between therapy response and the baseline ASF-scores, or differences in therapy outcomes between aMDD and naMDD patients. However, non-responders had higher ASF-scores, and at week 7 aMDD patients displayed a worse therapy outcome than naMDD patients. In subgroup analyses for different antidepressant drugs, venlafaxine-treated aMDD patients showed a significantly worse outcome at week 7. Future prospective, randomized-controlled studies should address the question of a worse therapy outcome in aMDD patients for different psychopharmaceuticals individually.

Abnormal white matter integrity in Papez circuit in first-episode medication-naive adults with anxious depression: A combined voxel-based analysis and region of interest study

BACKGROUND

Anxious depression is one of the subtypes of major depressive disorder (MDD), usually defined as "patients with MDD and high levels of anxiety symptoms". Compared to non-anxious MDD (naMDD), patients with anxious MDD (aMDD) have more severe depressive symptoms and suicidal ideation, worse treatment outcomes and remission rates, and poorer prognosis. Current research suggests that the Papez circuit is an important brain structure closely related to emotion, memory, and cognition. This study applied DTI to explore the altered white matter integrity in Papez circuit of patients with aMDD.

METHODS

DTI data were acquired from 30 medication-naive outpatients with naMDD and 55 with aMDD and 88 demographically similar healthy control (HC) subjects. Voxel-based analysis (VBM) and region of interest (ROI) analysis were conducted to explore the significant difference of fractional anisotropy (FA) values among 3 groups. Pearson's correlations were performed to analyze the correlation between FA values and the score of HAMA-14 and HAMD-17.

RESULTS

We found that aMDD patients had significantly higher FA values in left fornix (belong to Papez circuit) and left posterior thalamic radiation and right anterior corona radiata (belong to limbic-thalamo-cortical circuitry) compared with HC. And there was variability in the white matter integrity in right posterior thalamic radiation (belong to limbic-thalamo-cortical circuitry) and left fornix (belong to Papez circuit) between aMDD and naMDD patients.

LIMITATIONS

The cross-sectional study and the population vary between aMDD group and naMDD group are limitations.

CONCLUSIONS

Abnormal white matter integrity in Papez circuit and Limbic-Thalamo-Cortical circuitry may play an important role in the neuropathology of aMDD and might help to identify aMDD.

Venlafaxine vs. fluoxetine in postmenopausal women with major depressive disorder: an 8-week, randomized, single-blind, active-controlled study

BACKGROUND

In the population of postmenopausal patients with major depressive disorder (MDD), the superiority of serotonin-norepinephrine reuptake inhibitors (SNRIs) over selective serotonin reuptake inhibitors (SSRIs) has not yet been definitively proven. Consequently, a direct comparison of the efficacy of SSRIs and SNRIs in the treatment of postmenopausal depression could provide relevant data. The aim of this study was to compare the efficacy and safety of venlafaxine vs. fluoxetine in the treatment of postmenopausal MDD.

METHODS

This was an 8-week, multicenter, randomized, single-blind, active-controlled trial conducted at a psychiatric hospital (Beijing Anding Hospital) and a general hospital (Beijing Chaoyang Hospital) between April 2013 and September 2017. The primary outcome measure was improving depressive symptoms (Hamilton Depression Rating Scale (HAMD-24) score). The secondary outcomes included the change of HAMD-24 anxiety/somatization factor score and Clinical Global Impressions-Improvement (CGI-I) response rate. Safety was assessed by treatment-emergent adverse events (TEAEs) and laboratory tests. Efficacy was analyzed by using the full analysis set (FAS) following the modified intention-to-treat (mITT) principle. The primary endpoint measurements were analyzed using a mixed-effect model for repeated measures (MMRM) model with patients as a random-effect factor, treatment group as the independent variable, time as a repeated measure, and baseline covariates, using a first-order ante dependence covariance matrix.

RESULTS

A total of 184 women were randomized. The full analysis set (FAS) included 172 patients (venlafaxine, n = 82; fluoxetine, n = 90). Over the 8-week study period, the reduction in HAMD-24 scores was significant (P < 0.001) in both groups, while a significantly greater decline from baseline was observed in the venlafaxine group compared with the fluoxetine group (least-squares mean difference [95% CI]: - 2.22 [- 7.08, - 0.41]), P = 0.001). The baseline-to-week-8 least-squares mean change of the anxiety/somatization factor scores, CGI-I response rate were greater in the venlafaxine group than in the fluoxetine group (all P < 0.05). The most frequent TEAEs (≥5%) in both groups were nausea, somnolence, dizziness, headache, and dry mouth. There was no significant difference in the incidence of adverse events between the two groups.

CONCLUSION

Venlafaxine was well tolerated and compared to fluoxetine, it led to a greater improvement in the treatment of postmenopausal MDD.

TRIAL REGISTRATION

Clinical Trials. gov #NCT01824433 . The trial was registered on April 4, 2013.

Impaired fear learning and extinction, but not generalization, in anxious and non-anxious depression

Fear conditioning and generalization are well-known mechanisms in the pathogenesis of anxiety disorders. Extinction of conditioned fear responses is crucial for the psychotherapeutic treatment of these diseases. Anxious depression as a subtype of major depression shares characteristics with anxiety disorders. We therefore aimed to compare fear learning mechanisms in patients with anxious versus non-anxious depression. Fear learning mechanisms in patients with major depression (n = 79; for subgroup analyses n = 41 patients with anxious depression and n = 38 patients with non-anxious depression) were compared to 48 healthy participants. We used a well-established differential fear conditioning paradigm investigating acquisition, generalization, and extinction. Ratings of valence, arousal and probability of expected threat were assessed as well as skin conductance response as an objective psychophysiological measure. Patients with major depression showed impaired acquisition of conditioned fear. In addition, depressed patients showed impaired extinction of conditioned fear responses after successful fear conditioning. Generalization was not affected. However, there was no difference between patients with anxious and non-anxious depression. Results differed between objective and subjective measures. Our findings show altered fear acquisition and extinction in major depression as compared to healthy controls, but they do not favor differential fear learning and extinction mechanisms in the pathogenesis of anxious versus non-anxious depression. The results of impaired extinction warrant future studies addressing extinction learning elements in the treatment of depression.

The role of comorbid anxiety in exercise and depression trials: Secondary analysis of the SMILE-II randomized clinical trial

OBJECTIVES

To explore the anxiolytic effects of a 4-month randomized, placebo-controlled trial of exercise and antidepressant medication in patients with major depressive disorder (MDD), and to examine the potential modifying effects of anxiety in treating depressive symptoms.

MATERIALS AND METHODS

In this secondary analysis of the SMILE-II trial, 148 sedentary adults with MDD were randomized to: (a) supervised exercise, (b) home-based exercise, (c) sertraline, or (d) placebo control. Symptoms of state anxiety measured by the Spielberger Anxiety Inventory were examined before and after 4 months of treatment. Depressive symptoms were assessed by the Hamilton Depression Rating Scale (HAMD) and Beck Depression Inventory-II (BDI-II). Analyses were carried out using general linear models.

RESULTS

Compared to placebo controls, the exercise and sertraline groups had lower state anxiety scores (standardized difference = 0.3 [95% CI = -0.6, -0.04]; p = 0.02) after treatment. Higher pretreatment state anxiety was associated with poorer depression outcomes in the active treatments compared to placebo controls for both the HAMD (p = .004) and BDI-II (p = .02).

CONCLUSION

Aerobic exercise as well as sertraline reduced symptoms of state anxiety in patients with MDD. Higher levels of pretreatment anxiety attenuated the effects of the interventions on depressive symptoms, however, especially among exercisers. Patients with MDD with higher comorbid state anxiety appear to be less likely to benefit from exercise interventions in reducing depression and thus may require supplemental treatment with special attention to anxiety.

Comparative efficacy of add-on rTMS in treating the somatic and psychic anxiety symptoms of depression comorbid with anxiety in adolescents, adults, and elderly patients-A real-world clinical application

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is an effective adjuvant treatment for depression. Many patients with depression have comorbid anxiety symptoms. However, previous rTMS studies have focused on patients with depression, and often excluded comorbid anxiety. This real-world study aimed to investigate the comparative efficacy of add-on rTMS in treating the somatic and psychic anxiety symptoms of depression comorbid with anxiety in adolescents, adults and elderly patients.

METHODS

This study included 147 depression patients with anxiety symptoms who were treated with at least 10 sessions of rTMS. The symptoms of anxiety and depression were assessed with the Hamilton Rating Scale for Anxiety (HAMA) and the Hamilton Rating Scale for Depression (HAMD) at baseline and after 2 and 4 weeks of treatment. This was done to compare the improvement degree of add-on rTMS on somatic and psychic anxiety symptoms in adolescents, adults and elderly patients respectively.

RESULTS

Both somatic and psychic anxiety symptoms were significantly improved after the add-on rTMS in adolescents, adults and elderly patients. The improvement of somatic anxiety was better than that of psychic anxiety after rTMS treatment in elderly patients (t_2w=3.895, P<0.001; t_4w=2.823, P = 0.008).

LIMITATION

The overall sample was mostly composed of elderly patients, while adolescents and adult patients were fewer.

CONCLUSIONS

The add-on rTMS treatment can improve somatic anxiety better than psychic anxiety in depression with anxiety symptoms, especially in elderly patients.

The clinical characterization of the adult patient with depression aimed at personalization of management

Depression is widely acknowledged to be a heterogeneous entity, and the need to further characterize the individual patient who has received this diagnosis in order to personalize the management plan has been repeatedly emphasized. However, the research evidence that should guide this personalization is at present fragmentary, and the selection of treatment is usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the particular features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission with the first treatment they receive. The predominant pessimism about the actual feasibility of the personalization of treatment of depression in routine clinical practice has recently been tempered by some secondary analyses of databases from clinical trials, using approaches such as individual patient data meta-analysis and machine learning, which indicate that some variables may indeed contribute to the identification of patients who are likely to respond differently to various antidepressant drugs or to antidepressant medication vs. specific psychotherapies. The need to develop decision support tools guiding the personalization of treatment of depression has been recently reaffirmed, and the point made that these tools should be developed through large observational studies using a comprehensive battery of self-report and clinical measures. The present paper aims to describe systematically the salient domains that should be considered in this effort to personalize depression treatment. For each domain, the available research evidence is summarized, and the relevant assessment instruments are reviewed, with special attention to their suitability for use in routine clinical practice, also in view of their possible inclusion in the above-mentioned comprehensive battery of measures. The main unmet needs that research should address in this area are emphasized. Where the available evidence allows providing the clinician with specific advice that can already be used today to make the management of depression more personalized, this advice is highlighted. Indeed, some sections of the paper, such as those on neurocognition and on physical comorbidities, indicate that the modern management of depression is becoming increasingly complex, with several components other than simply the choice of an antidepressant and/or a psychotherapy, some of which can already be reliably personalized.

Blockade of NOP receptor modulates anxiety-related behaviors in mice exposed to inescapable stress

RATIONALE

Depression and anxiety frequently co-occur, and this has important clinical implications. Previous studies showed that activation of the nociceptin/orphanin FQ receptor (NOP) elicits anxiolytic effects, while its blockade promotes consistent antidepressant actions. NOP antagonists are effective in reversing footshock-induced depressive-like behaviors, but their effects on stress-induced anxiety are still unclear.

OBJECTIVE

This study aimed to investigate the effects of the NOP antagonist SB-612111 on footshock stress-induced anxiety behaviors.

METHODS

Male Swiss mice were exposed to inescapable electric footshock stress, and behavioral phenotype was screened based on the ability to escape from footshock (i.e., helpless or non-helpless). Animals were then treated with diazepam (1 mg/kg) and SB-612111 (0.1-10 mg/kg), and their behavior was assessed in the elevated plus-maze (EPM) and open field test.

RESULTS

When compared with non-stressed mice, helpless, but not non-helpless, animals displayed significant reductions in the time spent in and entries into open arms in the EPM. Diazepam significantly increased open arms exploration in helpless, non-helpless, and non-stressed mice. However, treatment with the NOP antagonist SB-612111 was inactive in naive mice, while it reversed anxiogenic-related behaviors in helpless mice and increased anxiety states in non-helpless mice. No effects on locomotion were observed.

CONCLUSION

Helpless mice displayed increased anxiety compared to non-stressed and non-helpless animals, thus supporting use of this approach as an animal model to investigate anxiety/depression comorbidity. Additionally, SB-612111 modulated anxiety-like behaviors in male mice depending on individual stress susceptibility. Ultimately, NOP antagonists could be useful for treating anxiety in depressed patients.

Comorbid Anxiety and Depression: Clinical and Conceptual Consideration and Transdiagnostic Treatment

Although anxiety and depression have been considered as two distinct entities according to the diagnostic criteria, anxious depression (comorbid anxiety and depression) is relatively a common syndrome. According to the DSM-5 criteria, it uses "with anxious distress specifier" to define anxious depression in its MDD section. Anxious depression is known to have different neurobiological profiles compared to non-anxious depression. Several studies have revealed significant differences between anxious depression and non-anxious depression regarding the hypothalamic-pituitary-adrenal (HPA) axis function, structural and functional brain imaging findings, inflammation markers, etc. Patients with anxious depression were significantly more likely to be found in primary care setting and more likely to be associated with female gender, non-single, unemployed, less educated, and more severe depression. Previous reports also showed that patients with anxious depression had more frequent episodes of major depression and a higher risk of suicidal ideation and previous suicide attempts than those with non-anxious depression. Although anxious depression is known to be associated with poor treatment outcomes in several studies, recent researches have sought to find better treatment strategy to improve patients with anxious depression.

Abnormal functional connectivity of habenula in untreated patients with first-episode major depressive disorder

Major depressive disorder (MDD) is associated with abnormalities in emotional/cognitive processing and low reward sensitivity. The habenula has a pivotal role in these processes that may contribute to depression. However, there has been little research on the abnormal connectivity between the habenula and whole brain of first-onset MDD. We aimed to explore the differences of functional connectivity between patients and healthy controls using functional magnetic resonance imaging. We used seed-based resting-state fMRI to examine functional connectivity between the habenula and whole-brain in 49 first-episode depressive patients and 25 healthy controls. Compared to controls, patients with MDD demonstrated significant increases in functional connectivity between the habenula and the dorsolateral prefrontal cortex (dlPFC). Furthermore, the receiver operating characteristic (ROC) curve proved that connectivity between the habenula and dlPFC was highly predictive. Additionally, there was a positive correlation between Hamilton Rating Scale for Depression (HAMD) score and functional connectivity between the habenula and right dlPFC. We found that the aberrant functional connectivity to the habenula and dlPFC can distinguish MDD patients from the normal.

Efficacy of venlafaxine extended release in major depressive disorder patients: effect of baseline anxiety symptom severity

Effects of baseline anxiety on the efficacy of venlafaxine extended release versus placebo were examined in a post hoc pooled subgroup analysis of 1573 patients enrolled in eight short-term studies of major depressive disorder. Anxiety subgroups were defined based on baseline 17-item Hamilton Rating Scale for Depression Item 10 score <3 (low) versus ≥3 (high). Change from baseline to final visit in Montgomery-Åsberg Depression Rating Scale total score and Montgomery-Åsberg Depression Rating Scale response and remission rates were analyzed. Change from baseline in Montgomery-Åsberg Depression Rating Scale total score and response and remission rates was significantly greater for venlafaxine extended release versus placebo in both low and high anxiety subgroups (all P < 0.0001). A statistically significant baseline anxiety by treatment interaction was observed for Montgomery-Åsberg Depression Rating Scale total score only (P = 0.0152). The adjusted mean change from baseline in Montgomery-Åsberg Depression Rating Scale total score was significantly greater in the high anxiety subgroup versus low anxiety subgroup for patients treated with venlafaxine extended release (-6.27 versus -3.89; P = 0.0440) but not placebo. These results support the efficacy of venlafaxine extended release for major depressive disorder treatment in patients with anxiety symptoms.

Is there a relationship between depression with anxious distress DSM-5 specifier and bipolarity? A multicenter cohort study on patients with unipolar, bipolar I and II disorders

BACKGROUND

To estimate the prevalence of DSM-5 anxious distress specifier (ADS) in depressed patients with major depressive disorder (MDD) or bipolar I or II disorder (BD), and to compare socio-demographic and clinical characteristics, and response to naturalistic short-term treatment between ADS and non-ADS group.

METHODS

241 outpatients with a major depressive episode (MDE) were consecutively recruited. Outcome were remission (HDRS₂₁ total score < 7), response (≥50% reduction of baseline HDRS₂₁) and improvement (CGI-i score ≤ 2) after 12 weeks of treatment sustained for 4 weeks.

RESULTS

ADS was more frequent in BD than in MDD (respectively, 66.9% and 51.2%, χ² = 6.1, p = 0.013). Compared with those non-ADS, patients with ADS had more severe depressive (respectively, HDRS₂₁ total score 20.0 ± 4.4 and 18.6 ± 3.9, t-test = 2.67, p = 0.008) and mania symptoms (respectively, Y-MRS total score 2.2 ± 2.9 and 1.3 ± 2.3, M-W-test = 2.86; p = 0.004) at intake, a higher rate of BD family history (respectively, 35.2% and 22.2%, Χ²-test 10.4, p = 0.004) and more previous hypomanic episodes (respectively, (median (range) 0 (0-20) and 0 (0-15), MW-test = 2.39 p = 0.017). In the MDD group, patients with ADS had higher scores on hyperthymic temperament and mania symptoms (Y-MRS total score (median (range) 2.2 (0-26) and 0 (0-11), respectively, M-W test 2.071, p = 0.038). ADS and no-ADS patients did not significantly differ on outcome measures.

LIMITATIONS

The observational nature of the study and the absence of blinding in outcome assessment.

CONCLUSIONS

ADS is the most common DSM-5 specifier for MDE, is more frequent in BD and need a personalized treatment with moderate use of antidepressants, mostly tricyclic.

What is anxious depression? Overlap and agreement between different definitions

Anxiety is common in depressed patients. However, a problem with the research on the significance of anxiety in depressed patients is that anxiety has been characterized in different ways. Little research has examined the concordance and overlap between the various definitions of anxious depression. With research on the DSM-5 anxious distress specifier just beginning, it will be important to understand how defining anxious depression according to DSM-5 agrees with previously studied definitions. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the DSM-5 anxious distress specifier and 6 other approaches towards defining anxious depression. Three hundred thirty-one patients with a principal diagnosis of major depressive disorder were evaluated with semi-structured diagnostic interviews. The mean number of anxious depression definitions met was 4.7 (SD = 2.1). Only 4.2% (n = 14) of the 331 patients did not meet any anxious depression definition, and 28.1% (n = 93) met all 7 definitions. The level of agreement between the definitions was significant, albeit modest (median kappa = .28). The modest association between the different definitions of anxious depression suggests that the results based on one approach towards subtyping may not generalize to the DSM-5 anxious distress specifier. It therefore cannot be assumed that the DSM-5 anxious distress specifier is valid just because other definitions of anxious depression have been shown to be valid.

Quality of Life Assessment in Antidepressant Treatment of Patients with Depression and/or Anxiety Disorder

Introduction:

The concept of quality of life (QoL) is becoming an increasingly important criterion in the assessment of treatment outcomes, health outcomes and in the assessment of the benefit-to-load ratio of drugs or therapies that have equivalent mechanisms of action.

Aim:

The aim of the study was to evaluate the improvement of quality of life, tolerability of therapy and patient compliance in patients with depression and/or anxiety disorder treated with antidepressants.

Methods:

The study was designed as a clinical, multicenter, prospective, cohort study involving 682 patients of both sexes diagnosed with depression and/or anxiety disorder observed over the 9 months period. The study was conducted from January to December 2017 in six research centers of the PI Health Center of the Canton of Sarajevo. The patients were divided into three groups: depressive, anxious and mixed anxiety-depressive disorder, and the therapy administered was, paroxetine or escitalopram. MOS (Medical Outcomes Study) sleep scale and Q-LES-Q-SF (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form) scale were used for quality of life evaluation. Patients were observed six times over the course of the study.

Results:

The results of the MOS questionnaire showed that more than 90 percent of patients with depression and/or anxiety disorder who had taken fluoxetine, paroxetine or escitalopram for 36 weeks experienced an improvement in the sleep problem index. Sleep duration was greatly improved in all patients regardless of the antidepressants used. The results of the Q-LES-Q-SF questionnaire showed a significant improvement in quality of life as well as overall pleasure and satisfaction with life due to the use of antidepressants.

Conclusion:

Therapy with fluoxetine, paroxetine and escitalopram leads to a significant improvement of all recorded parameters, along with the overall quality of life, which makes them very effective in the treatment of depression and/or anxiety disorders.

The influence of comorbid anxiety on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder

BACKGROUND

Anxious depression is an important subtype of Major Depressive Disorder (MDD) defined by both syndromal (anxiety disorders) and dimensional (anxiety symptoms) criteria. A debated question is how anxiety affects MDD treatment. This study examined the impact of comorbid anxiety disorders and symptoms on the effectiveness of and dropout during Cognitive Therapy (CT) and Interpersonal Psychotherapy (IPT) for MDD.

METHODS

Depressed individuals were randomized to CT (n = 76) or IPT (n = 75). Outcome was depression severity measured with the Beck Depression Inventory-II (BDI-II) at the start of each therapy session, post treatment, and monthly up to five months follow-up. Anxiety disorders were assessed with the Structured Clinical Interview for DSM-IV Axis I disorders, (phobic) anxiety symptoms were assessed with Brief Symptom Inventory subscales.

RESULTS

Approximately one third of participants had a comorbid anxiety disorder. Comorbid anxiety disorders and anxiety symptoms were associated with less favorable depression change during IPT as compared to CT in the treatment phase, but not in the trial follow-up phase. Individuals with a comorbid anxiety disorder had significantly higher treatment dropout during both treatments.

LIMITATIONS

Not all therapists and participants were blind to the assessment of comorbid anxiety disorders and the assessments were performed by one rater.

CONCLUSIONS

A preference for CT over IPT for MDD is justifiable when comorbid anxiety is present, although long-term differences are not established and replication of this finding is needed. Clinicians should be aware of the risk of dropout for depressed individuals with an anxiety disorder.

Subtypes of depression and their overlap in a naturalistic inpatient sample of major depressive disorder

Subtyping depression is important in order to further delineate biological causes of depressive syndromes. The aim of this study was to evaluate clinical and outcome characteristics of distinct subtypes of depression and to assess proportion and features of patients fulfilling criteria for more than one subtype. Melancholic, atypical and anxious subtypes of depression were assessed in a naturalistic sample of 833 inpatients using DSM-IV specifiers based on operationalized criteria. Baseline characteristics and outcome criteria at discharge were compared between distinct subtypes and their overlap. A substantial proportion of patients (16%) were classified with more than one subtype of depression, 28% were of the distinct anxious, 7% of the distinct atypical and 5% of the distinct melancholic subtype. Distinct melancholic patients had shortest duration of episode, highest baseline depression severity, but were more often early improvers; distinct anxious patients had higher NEO-Five Factor Inventory (NEO-FFI) neuroticism scores compared with patients with unspecific subtype. Melancholic patients with overlap of anxious features had worse treatment outcome compared to distinct melancholic and distinct anxious subtype. Distinct subtypes differed in only few variables and patients with overlap of depression subtypes may have independent clinical and outcome characteristics. Studies investigating biological causes of subtypes of depression should take influence of features of other subtypes into account.

Relationship Between the DSM-5 Anxious Distress Specifier and the Hamilton Depression Rating Scale Anxiety/Somatization Factor

We examined the association between the Hamilton Depression Scale (HAMD) approach to classifying depressed patients into anxious and nonanxious subgroups and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) anxious distress specifier subtyping. Two hundred two depressed patients were interviewed with semistructured diagnostic interviews. Patients were rated on the 17-item HAMD and the Hamilton Anxiety Rating Scale and completed the Clinically Useful Anxiety Outcome Scale. Both approaches toward identifying anxiety in depressed patients resulted in most of the patients meeting the anxiety subtype. Both subtyping methods were significantly correlated with clinician-rated and self-report measures of anxiety, and scores on the anxiety scales were higher in the patients who met the anxious subtype. However, DSM-5 anxious distress subtyping was only marginally associated with the HAMD anxiety/somatization factor subtyping approach (k = 0.21), and dimensional scores were only moderately correlated (r = 0.50). These findings indicate that the DSM-5 and HAMD approaches toward identifying an anxious subtype of depression are not interchangeable.

A preliminary assessment of a combination of rhodiola and saffron in the management of mild-moderate depression

OBJECTIVE

The medicinal plants Rhodiola rosea L. (rhodiola, golden root) and Crocus sativus L. (saffron) have been shown separately to induce significant effects in depression. The objective of this study was to assess a fixed combination of rhodiola and saffron in mild-moderate depression.

METHODS

In this observational study conducted with general practitioners (GPs), 45 adults (aged 18-85 years) suffering from mild or moderate depression (International Statistical Classification of Diseases and Related Health Problems 10th Revision definition) and reaching a score on the Hamilton Rating Scale for Depression of 8-18 were supplemented with a combination of rhodiola and saffron extracts (one tablet, 154 mg of rhodiola and 15 mg of saffron; recommended dose two tablets per day for 6 weeks).

RESULTS

After 6 weeks (D42) of supplementation, Hamilton Rating Scale for Depression scores (primary outcome) decreased significantly by 58%±28.5% (from 13.6±2.3 at D0 to 5.6±3.8 at D42, P<0.0001; n=41). Score improvement was reported in 85.4% of patients. A significant drop in both Hospital Anxiety and Depression Scale anxiety and depression scores was also observed at D42, the decrease being significant from 2 weeks of supplementation. At the end of the study, both GPs and patients deemed there was a significant improvement in depression (Clinical Global Impression - improvement and Patient Global Impression of Change). Safety was excellent, and no serious adverse effects were recorded.

CONCLUSION

Results of this observational study performed in primary care suggest that the combination of rhodiola and saffron tested could be useful for the management of mild-moderate depression and improve depressive and anxiety symptoms. A double-blind placebo-controlled study is needed to confirm these results.

Patients with anxious depression: overview of prevalence, pathophysiology and impact on course and treatment outcome

PURPOSE OF REVIEW

Major depressive disorder with a comorbid anxiety disorder or with significant anxiety symptoms (here called anxious depression) is common and has been associated with poor clinical course trajectories. However, various dichotomous as well as dimensional definitions have been used to label anxious depression and it remains unclear to which extent these result in inconsistent findings. This review provides an overview of recent literature on the impact of anxiety in depressed patients on clinical course trajectories, treatment outcomes, and underlying neurobiological dysregulations.

RECENT FINDINGS

Anxious depression seems associated with poorer clinical course trajectories and treatment nonresponse as compared with 'pure' depression, regardless of which definition is used. Recent studies have attempted to determine specific efficacy of novel pharmacological treatments for anxious depressed patients, but have not been conclusive because of the insufficient number of studies and differences in definitions and assessment of anxious depression. Neurobiology studies suggest that anxious depression is associated with increased immune dysregulation, more cortical thinning, and corticolimbic dysfunctions as compared with 'pure' depression.

SUMMARY

Anxious depression appears to be a common and clinically relevant subtype of depression as it predicts poorer course trajectories. As populations with anxious depression may benefit from specific treatment regimens, further research is necessary to better delineate its definition and neurobiology. The relatively new Diagnostic and Statistical Manual of Mental Disorders-5 anxious distress specifier is a welcome development and should be further investigated and compared against other anxiety constructs.

Striatal dopamine D2/3 receptor-mediated neurotransmission in major depression: Implications for anhedonia, anxiety and treatment response

Dopamine (DA) neurotransmission within the brain's reward circuit has been implicated in the pathophysiology of depression and in both, cognitive and pharmacological mechanisms of treatment response. Still, a direct relationship between measures of DA neurotransmission and reward-related deficits in patients with depression has not been demonstrated. To gain insight into the symptom-specific alterations in the DA system in patients with depression, we used positron emission tomography (PET) and the D_2/3 receptor-selective radiotracer [¹¹C]raclopride in twenty-three non-smoking un-medicated Major Depressive Disorder (MDD) patients and sixteen healthy controls (HC). We investigated the relationship between D_2/3 receptor availability and baseline measures of depression severity, anxiety, anhedonia, and cognitive and pharmacological mechanisms of treatment response. We found that, compared to controls, patients with depression showed greater D_2/3 receptor availability in several striatal regions, including the bilateral ventral pallidum/nucleus accumbens (vPAL/NAc), and the right ventral caudate and putamen. In the depressed sample, D_2/3 receptor availability in the caudal portion of the ventral striatum (NAc/vPAL) correlated with higher anxiety symptoms, whereas D_2/3 receptor availability in the rostral area of the ventral striatum correlated negatively with the severity of motivational anhedonia. Finally, MDD non-remitters showed greater baseline anxiety, greater D_2/3 availability in the NAc/vPAL, and greater placebo-induced DA release in the bilateral NAc. Our results demonstrate abnormally high D_2/3 receptor availability in the ventral striatum of patients with MDD, which seem to be associated with comorbid anxiety symptoms and lack of response to antidepressants.

Reliability and validity of the DSM-5 Anxious Distress Specifier Interview

BACKGROUND

To acknowledge the clinical significance of anxiety in depressed patients, DSM-5 included an anxious distress specifier for major depressive disorder (MDD). In the present report we describe the reliability and validity of a semi-structured interview assessing the features of the anxious distress specifier. Our goal was to develop an instrument that could be used for both diagnostic and outcome measurement purposes.

METHODS

One hundred seventy-three psychiatric patients with MDD were interviewed by a trained diagnostic rater who administered the Structured Clinical Interview for DSM-IV (SCID) supplemented with questions from the DSM-5 Anxious Distress Specifier Interview (DADSI). Inter-rater (n=25) and test-retest (n=25) reliability of the DADSI was examined in separate groups of patients. The patients were rated on clinician rating scales of depression, anxiety and irritability, and patients completed self-report measures of these constructs. Sensitivity to change was examined in 16 patients.

RESULTS

Approximately three-quarters of the depressed patients met the criteria for the anxious distress specifier (78.0%, n=135). The DADSI had excellent joint-interview reliability and good test-retest reliability. DADSI total scores were more highly correlated with other clinician-rated and self-report measures of anxiety than with measures of depression and anger. DADSI scores were significantly higher in depressed outpatients with a current anxiety disorder than depressed patients without a comorbid anxiety disorder. The DADSI was sensitive to improvement.

CONCLUSION

The DADSI is a reliable and valid measure of the presence of the DSM-5 anxious distress specifier for MDD as well as the severity of the features of the specifier.

Lurasidone for major depressive disorder with mixed features and anxiety: a post-hoc analysis of a randomized, placebo-controlled study

OBJECTIVE

The aim of this post-hoc analysis was to evaluate the efficacy of lurasidone in treating patients with major depressive disorder (MDD) with mixed features who present with mild and moderate-to-severe levels of anxiety.

METHODS

The data in this analysis were derived from a study of patients meeting the DSM-IV-TR criteria for unipolar MDD, with a Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥26, presenting with two or three protocol-defined manic symptoms, who were randomized to 6 weeks of double-blind treatment with either lurasidone 20-60 mg/day (n=109) or placebo (n=100). Anxiety severity was evaluated using the Hamilton Anxiety Rating Scale (HAM-A). To evaluate the effect of baseline anxiety on response to lurasidone, the following two anxiety groups were defined: mild anxiety (HAM-A≤14) and moderate-to-severe anxiety (HAM-A≥15). Change from baseline in MADRS total score was analyzed for each group using a mixed model for repeated measures.

RESULTS

Treatment with lurasidone was associated with a significant week 6 change versus placebo in MADRS total score for patients with both mild anxiety (-18.4 vs. -12.8, p<0.01, effect size [ES]=0.59) and moderate-to-severe anxiety (-22.0 vs. -13.0, p<0.001, ES=0.95). Treatment with lurasidone was associated with a significant week 6 change versus placebo in HAM-A total score for patients with both mild anxiety (-7.6 vs. -4.0, p<0.01, ES=0.62), and moderate-to-severe anxiety (-11.4 vs. -6.1, p<0.0001, ES=0.91).

CONCLUSIONS

In this post-hoc analysis of an MDD with mixed features and anxiety population, treatment with lurasidone was associated with significant improvement in both depressive and anxiety symptoms in subgroups with mild and moderate-to-severe levels of anxiety at baseline.

A meta-analysis of the efficacy of venlafaxine extended release 75-225 mg/day for the treatment of major depressive disorder

OBJECTIVE

To evaluate the short-term efficacy of venlafaxine extended release (ER) 75-225 mg/day compared with placebo for treating major depressive disorder (MDD) and to examine associations between baseline characteristics and efficacy outcomes in MDD patients treated with venlafaxine ER 75-225 mg/day.

RESEARCH DESIGN AND METHODS

This meta-analysis included published and unpublished short-term, double-blind, placebo-controlled, Wyeth/Pfizer sponsored studies of venlafaxine ER at doses up to 225 mg/day in adults with MDD.

CLINICAL TRIAL REGISTRATION

All trials were conducted before trial registration became mandatory.

MAIN OUTCOME MEASURES

Change from baseline in the 17-item Hamilton Rating Scale for Depression (HAM-D₁₇) total score was analyzed over time using a mixed-effects model for repeated measures with terms for study, treatment group, visit, interaction between treatment group and visit, and baseline score as a covariate. Associations between baseline demographic and clinical characteristics and the probability of HAM-D₁₇ response and remission at week 8 were evaluated using logistic regression models, with terms for study, treatment group, and baseline characteristics in the models. Safety and tolerability was assessed based on adverse events (AEs) and discontinuations due to AEs.

RESULTS

The full analysis set included 1087 patients from five studies that fulfilled selection criteria. Statistically significant separation between venlafaxine ER and placebo groups for HAM-D₁₇ total score was seen at week 2 and all subsequent assessments (p-values <.0001). There was no significant interaction between treatment and baseline HAM-D₁₇ total score. Probability of HAM-D₁₇ remission at week 8 decreased with increasing baseline HAM-D₁₇ total score (p = .0012; OR: 0.94); however, baseline HAM-D₁₇ total score did not predict response. Discontinuations due to AEs were reported for 9.4% of venlafaxine-ER-treated patients compared with 3.6% of placebo-treated patients. Key limitations: Five studies met the criteria for inclusion. Several differences in design between included studies limited the analysis: one study did not include a week 3 assessment (the week 3 time point was therefore dropped from the analysis), one study had two venlafaxine ER dose arms, which were combined into one group for the meta-analysis, and mixed- and flexible-dose studies were pooled.

CONCLUSIONS

Venlafaxine ER 75-225 mg/day effectively reduced symptoms of depression in patients with MDD overall and in patients with either lower (≤23) or higher (>23) HAM-D₁₇ total score at baseline.

Anxious distress predicts subsequent treatment outcome and side effects in depressed patients starting antidepressant treatment

Evidence has shown that the DSM-5 anxious distress specifier captures a clinically valid construct that predicts a worse clinical course. Although of importance for treatment planning and monitoring, however, the specifier's ability to predict treatment outcome is unknown. This is the first study to examine the ability of the DSM-5 anxious distress specifier to predict treatment response and side effects in depressed patients who recently initiated antidepressant treatment. Patients were from the Netherlands Study of Depression and Anxiety, an ongoing longitudinal cohort study. Baseline, 1-year and 2-year follow-up data were used from 149 patients (18-65 years) with current Major Depressive Disorder (MDD) who recently started adequately dosed antidepressant medication. Five self-report items were used to construct the DSM-5 anxious distress specifier. Treatment outcomes were depression severity after 1 year and 2 years, remission of MDD after 2 years and antidepressant side effects during treatment. For comparison, analyses were repeated for comorbid DSM-IV-based anxiety disorders as a predictor. In depressed patients who received antidepressant treatment, the anxious distress specifier (prevalence = 59.1%) significantly predicted higher severity (1 year: B = 1.94, P = 0.001; 2 years: B = 1.63, P = 0.001), lower remission rates (OR = 0.44, P = 0.0496) and greater frequency of side effects (≥4 vs. 0: OR = 2.74, P = 0.061). In contrast, the presence of comorbid anxiety disorders did not predict these treatment outcomes. The anxious distress specifier significantly predicts poorer treatment outcomes as shown by higher depression severity, lower remission rates, and greater frequency of antidepressant side effects in patients with MDD on adequate antidepressant treatment. Therefore, this simple 5-item specifier is of potential great clinical usefulness for treatment planning and monitoring in depressed patients.

Formulation and Characterization of Nanomedicine (Solid Lipid Nanoparticle) Associate with the Extract of Pterospermum acerifolium for the Screening of Neurochemicals and Neuroendocrine Effects

Background:

Nanotechnology has given the likelihood of conveying medications to particular cells utilizing nanoparticles. Nanosystems can convey the dynamic constituent at an adequate fixation amid the whole treatment time frame, guiding it to the fancied site of activity. Traditional medications do not meet these necessities. The fundamental motivation behind creating elective medication conveyance advancements is to expand effectiveness of medication conveyance and security during the time spent medication conveyance and give more accommodation to the patient.

Objectives:

Pterospermum acerifolium, basic plant in India, is viewed as carminative, stimulant, and emmenagogue. The improvement of control discharge conveyance systems could prompt huge preferences in the clinical employments of these medications to diminish the toxicities. The point of this study was to figure another conveyance framework for impacts of neurochemicals by the joining of concentrate of P. acerifolium into strong lipid nanoparticles (SLNs).

Methods:

SLN formulations were prepared by Ethanolic extract, lipid layer was liquefied by warming at 5°C above liquefying purpose of the lipid. After that, SLNs were separated and dried. Shape and surface morphology of the SLNs were pictured by checking scanning electron microscopy. Particle size and size distribution were dictated by photon connection spectroscopy.

Results and Discussion:

The change of molecule charge was contemplated by zeta potential estimations. Treatment with SLN with concentrate was found to altogether diminish the serum levels of adrenocorticotropic hormone (ACTH), corticosterone and-endorphin and in addition the cerebrum and serum level of norepinephrine. Moreover, SLN with concentrate could essentially turn around the constant anxiety by diminishing the cerebrum and serum levels of the monoamine neurotransmitters dopamine, 5-hydroxytryptamine.

Conclusion:

The outcomes got from this study recommended that the memory-improving impact of SLN with concentrate was interceded through directions of neurochemical and neuroendocrine frameworks.

A meta-analysis of the efficacy of vortioxetine in patients with major depressive disorder (MDD) and high levels of anxiety symptoms

BACKGROUND

Coexisting anxiety is common in major depressive disorder (MDD) and more difficult to treat than depression without anxiety. This analysis assessed the efficacy, safety, and tolerability of vortioxetine in MDD patients with high levels of anxiety (baseline Hamilton Anxiety Rating Scale [HAM-A] total score ≥20).

METHODS

Efficacy was assessed using an aggregated, study-level meta-analysis of 10 randomized, placebo-controlled, 6/8-week trials of vortioxetine 5-20mg/day in adults (18-75 years), with a study in elderly patients (≥65 years) analyzed separately. Outcome measures included mean differences from placebo in change from baseline to endpoint (Δ) in the Montgomery-Åsberg Depression Rating Scale (MADRS), HAM-A total, and HAM-A subscales. Safety and tolerability were assessed by treatment-emergent adverse events (TEAEs).

RESULTS

A total of 1497 (48.6%) vortioxetine-treated and 860 (49.1%) placebo-treated patients had baseline HAM-A≥20. There were significant differences from placebo in MADRS (vortioxetine 5mg/day, n=415, Δ-2.68, P=0.005; 10mg/day, n=373, Δ-3.59, P<0.001; 20mg/day, n=207, Δ-4.30, P=0.005) and HAM-A total (5mg/day, n=419, Δ-1.64, P=0.022; 10mg/day, n=373, Δ-2.04, P=0.003; 20mg/day, n=207, Δ-2.19, P=0.027). There were significantly greater improvements versus placebo on the HAM-A psychic subscale for all doses. The most common TEAEs (≥5.0%) were nausea, headache, dizziness, dry mouth, diarrhea, nasopharyngitis, constipation, and vomiting. Incidence of serious TEAEs was 1.3% (placebo) and ≤1.3% (vortioxetine, across doses).

LIMITATIONS

Study heterogeneity limits this analysis. Patients with baseline HAM-A≥20 were not directly compared to baseline HAM-A<20 or total MDD population.

CONCLUSIONS

Vortioxetine was efficacious in reducing depressive and anxiety symptoms in patients with MDD and high levels of anxiety.

On the Complexity of Brain Disorders: A Symptom-Based Approach

Mounting evidence shows that brain disorders involve multiple and different neural dysfunctions, including regional brain damage, change to cell structure, chemical imbalance, and/or connectivity loss among different brain regions. Understanding the complexity of brain disorders can help us map these neural dysfunctions to different symptom clusters as well as understand subcategories of different brain disorders. Here, we discuss data on the mapping of symptom clusters to different neural dysfunctions using examples from brain disorders such as major depressive disorder (MDD), Parkinson’s disease (PD), schizophrenia, posttraumatic stress disorder (PTSD) and Alzheimer’s disease (AD). In addition, we discuss data on the similarities of symptoms in different disorders. Importantly, computational modeling work may be able to shed light on plausible links between various symptoms and neural damage in brain disorders.

[Treatment of endogenous depression with venflaxine: clinical action, tolerability and personalized treatment options]

OBJECTIVE

To specify clinical action of venflaxine during the course treatment of patients with different depressive states of endogenous nature.

MATERIAL AND METHODS

An open naturalistic study of 32 patients with different nosological forms of endogenous depression (manic-depressive psychosis, cyclothymia, schizophrenia) was carried out. Duration of the course treatment with venflaxine (velaxin) administered in daily dose of 37,5-300 mg was 56 days. Clinical and psychometric methods were used.

RESULTS

Venflaxine was a highly effective antidepressant. In the end of treatment, a "good" therapeutic effect with >50% reduction in total scores on the Hamilton scale (HAMD-D) was achieved in 84,4% of patients, a "marked" effect up to complete recovery with >80% reduction in HAMD-D scores was in 78,1% of cases.

CONCLUSION

Due to its clinical characteristics, venflaxine may be regarded as a multiprofile antidepressant with the distinct balanced action. In the spectrum of its antidepressant activity, a thymoleptic effect is most pronounced compared to anxiolytic and stimulating effects. This provides a high efficacy of the drug in different types of endogenous depression (anxiety, apatho-adynamic and, in particular, melancholic).

Differential impact of anxiety symptoms and anxiety disorders on treatment outcome for psychotic depression in the STOP-PD study

BACKGROUND

There are conflicting results on the impact of anxiety on depression outcomes. The impact of anxiety has not been studied in major depression with psychotic features ("psychotic depression").

AIMS

We assessed the impact of specific anxiety symptoms and disorders on the outcomes of psychotic depression.

METHODS

We analyzed data from the Study of Pharmacotherapy for Psychotic Depression that randomized 259 younger and older participants to either olanzapine plus placebo or olanzapine plus sertraline. We assessed the impact of specific anxiety symptoms from the Brief Psychiatric Rating Scale ("tension", "anxiety" and "somatic concerns" and a composite anxiety score) and diagnoses (panic disorder and GAD) on psychotic depression outcomes using linear or logistic regression. Age, gender, education and benzodiazepine use (at baseline and end) were included as covariates.

RESULTS

Anxiety symptoms at baseline and anxiety disorder diagnoses differentially impacted outcomes. On adjusted linear regression there was an association between improvement in depressive symptoms and both baseline "tension" (coefficient=0.784; 95% CI: 0.169-1.400; p=0.013) and the composite anxiety score (regression coefficient = 0.348; 95% CI: 0.064-0.632; p=0.017). There was an interaction between "tension" and treatment group, with better responses in those randomized to combination treatment if they had high baseline anxiety scores (coefficient=1.309; 95% CI: 0.105-2.514; p=0.033). In contrast, panic disorder was associated with worse clinical outcomes (coefficient=-3.858; 95% CI: -7.281 to -0.434; p=0.027) regardless of treatment.

CONCLUSIONS

Our results suggest that analysis of the impact of anxiety on depression outcome needs to differentiate psychic and somatic symptoms.

Pharmacologic treatment of dimensional anxious depression: a review

OBJECTIVE

To review the pharmacologic treatment of dimensionally defined anxious depression.

DATA SOURCES

English-language, adult human research articles published between 1949 and February 2013 were identified via PUBMED and EMBASE. The search term was treatment of anxious depression.

STUDY SELECTION

We identified and reviewed 304 original articles. Of these, 31 studies of patients with anxious depression, who were treated with an antidepressant or antipsychotic, are included in this review.

DATA EXTRACTION

All studies explicitly used a dimensional definition of anxious depression. All patients were treated with either antidepressants or antipsychotic medications.

RESULTS

Of the 31 relevant psychopharmacologic studies identified, 7 examined patients receiving only 1 medication, 2 studied cotherapeutic strategies, 1 examined antipsychotic augmentation, and 21 compared multiple medications. Eleven were pooled analyses from several studies. All studies were of adults (18-92 years old). The Hamilton Depression Rating Scale Anxiety/Somatization Factor Score was used to define anxious depression in 71% of the studies, and 77.4% were post hoc analyses of previous datasets. Seventeen studies found selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and/or tricyclic antidepressants (TCAs) to be useful for successfully treating anxious depression. However, patients with anxious depression were less likely to experience sustained response or remission. Furthermore, baseline anxious depression puts patients at greater risk for side effect burden.

CONCLUSIONS

Despite achieving response with SSRIs, SNRIs, and TCAs, patients with dimensionally defined anxious depression do not maintain response or remission and often report a larger burden of side effects compared to nonanxious depressive patients, suggesting that it is a harder-to-treat subtype of major depressive disorder.

Extended release quetiapine fumarate as adjunct to antidepressant therapy in patients with major depressive disorder: pooled analyses of data in patients with anxious depression versus low levels of anxiety at baseline

OBJECTIVES

To evaluate quetiapine XR in patients with anxious depression, as defined by HAM-A total and HAM-D anxiety/somatisation factor scores.

METHODS

Post hoc analyses of pooled data from two 6-week, double-blind, randomised, placebo-controlled studies of adjunctive quetiapine XR (150 or 300 mg/day) in patients with MDD and inadequate response to antidepressants. Patients were stratified in a primary analysis using HAM-A (HAM-A total score at baseline ≥ 20 ["high"] or < 20 ["low"]) and a secondary analysis using HAM-D (anxious depression defined as HAM-D anxiety/somatisation factor score ≥ 7). Outcomes included change in MADRS total score.

RESULTS

In patients with high anxiety levels (HAM-A total score ≥ 20), reductions in MADRS total score were -15.20 (P = 0.122) and -15.92 (P < 0.05) for quetiapine XR 150 and 300 mg/day, respectively, vs. placebo (-13.49). In patients with low levels of anxiety (HAM-A total score < 20), both quetiapine XR doses (P < 0.001) improved MADRS total scores vs. placebo. In the secondary analysis, quetiapine XR 150 (P < 0.01) and 300 mg/day (P < 0.001) improved MADRS total score vs. placebo in patients with HAM-D anxiety/somatisation factor score ≥ 7.

CONCLUSIONS

Adjunct quetiapine XR demonstrates efficacy in patients with anxious and non-anxious depression, assessed using HAM-A total score, and anxious depression assessed using HAM-D anxiety/somatisation factor score.

Reducing the Burden of Difficult-to-Treat Major Depressive Disorder: Revisiting Monoamine Oxidase Inhibitor Therapy

OBJECTIVE

Difficult-to-treat depression (eg, depression with atypical or anxious symptoms, treatment-resistant depression, or depression with frequent recurrence) is a challenging real-world health issue. This critical review of the literature focuses on monoamine oxidase inhibitor (MAOI) therapy and difficult-to-treat forms of depression.

DATA SOURCES

A literature search was performed in November 2012 and refreshed through January 2013 with no date restrictions using key search terms including MAO inhibitor therapy or MAOI and depression and anxiety, atypical, treatment-resistant, recurrent, relapse, or refractory.

STUDY SELECTION

Articles were selected to summarize the current needs in difficult-to-treat depression as well as the use of MAOI therapies in this area.

RESULTS

Two strategies have fallen out of favor in the care of patients with major depressive disorder. The first is the use of MAOI therapy and the second is the proactive recognition of difficult-to-treat depression that may not respond as well to more frequently used antidepressants. The infrequent use of MAOIs stems from the perception that other oral therapies for depression are safer and easier to use than oral MAOIs; however, transdermal delivery is one potential strategy to improve the safety of this class of agents. Although food-related interactions with transdermal delivery of MAOI therapy can be lessened, clinicians still need to be vigilant for drug-drug interactions and serotonin syndrome.

CONCLUSIONS

Clinicians should consider MAOIs for patients who have had several unsuccessful trials of antidepressants. Guidelines generally reserve MAOIs as third- and fourth-line treatments due to concerns over safety and tolerability; however, transdermal delivery of an MAOI may allay some of the safety and tolerability concerns. Patients should be provided education about MAOIs and their risks.

Acute and long-term treatment outcome in depressed inpatients with vs. without anxious features: results of a one-year follow-up study

BACKGROUND

Anxious depression (AD) is common in patients with unipolar depression. It remains unclear if they have a higher level of depressive symptoms, a higher risk of non-response, a poorer prognosis and a higher relapse rate compared to non-anxious depressed (non-AD) patients.

METHODS

168 patients took part in all three measurement points: (1) intake, (2) discharge and (3) follow-up. Patients fulfilled the criteria for anxious depression if they had a baseline score >7 on the anxiety/somatisation factor of the Hamilton Rating Scale for Depression (HRSD). Patients with AD and non-AD were compared regarding symptom reduction from intake to discharge as well as from discharge to one year after discharge. Primary outcome measure was the HRSD.

RESULTS

The prevalence of AD was considerably high (81%). At intake, patients with AD had a significant higher score in the modified HRSD (M=20.67±4.12 vs. M=14.35±5.06). Both patient groups showed a significant and comparable intake-to-discharge symptom reduction in all inventories. Remission rates at discharge did not differ between AD and non-AD patients. At 1-year follow-up, AD patients showed a similar symptom severity compared to non-AD patients.

CONCLUSION

Symptoms of anxiety are common in depressive disorders are associated with higher depressive symptoms at the beginning of treatment. Acute and longer-term treatment outcome of AD patients was comparable to that of non-AD patients.

LIMITATIONS

Limitations of this study are the naturalistic design, treatment was not standardized and comorbid anxiety disorders were not assed using a structured interview.

Difference in remission in a Chinese population with anxious versus nonanxious treatment-resistant depression: a report of OPERATION study

BACKGROUND

A secondary analysis was conducted to compare treatment outcomes for anxious depression and nonanxious depression in previous published OPERATION trials of a variety of antidepressants and augmentation strategies for patients with treatment-resistant depression (TRD).

METHODS

A total of 375 patients that met DSM-IV criteria for major depressive disorder (MDD) and the stage 2 TRD criteria (described by Thase & Rush) were enrolled. Anxious depression was defined as MDD with a HRSD-17 anxiety/somatization factor score ≥7. Data were derived from an earlier study, designed to compare efficacy and tolerability of fixed dosage of extended-release venlafaxine, mitazapine, paroxetine, and risperidone, sodium valproate, buspirone, trazodone or thyroid hormone augmenting to paroxetine in those patients. Treatment outcomes were compared between patients with anxious and nonanxious TRD.

RESULTS

Nearly 70% of participants had anxious depression. Remission rates were significantly lower and ratings of adverse event frequency were significantly greater in patients with anxious TRD than in those with nonanxious TRD. Presence of anxious depression predicted worse outcomes.

LIMITATIONS

Lack of a placebo control arm prevents us from ruling out placebo effects. The two groups were non-randomly allocated to medications. Only patients with stage 2 TRD were enrolled, which may limit generalizablity to patients without a history of resistance. Comorbid anxiety disorders that might confound the specific treatment effects were not addressed.

CONCLUSIONS

The findings support and extend the hypothesis that anxious depression is associated with poorer outcomes. It suggests a dimensional assessment of co-occurring anxious features of MDD patients may be clinically feasible for countries like China where difficulties in making comorbidity diagnosis exist.

Physical co-morbidity among treatment resistant vs. treatment responsive patients with major depressive disorder

Co-morbid physical illness has been suggested to play an important role among the factors contributing to treatment resistance in patients with major depressive disorder. In the current study we compared the rate of physical co-morbidity, defined by ICD-10, among a large multicenter sample of 702 patients with major depressive disorder. A total of 356 of the participants were defined as treatment resistant depression (TRD) patients-having failed two or more adequate antidepressant trials. No significant difference was found between TRD and non-TRD participants in the prevalence of any ICD-10 category. This finding suggests that although physical conditions such as diabetes, thyroid dysfunction, hypertension, ischemic heart disease, and peptic diseases are often accompanied by co-morbid MDD, they do not necessarily have an impact on the course of MDD or the likelihood to respond to treatment. Marginally higher rates of co-morbid breast cancer, migraine and glaucoma were found among TRD participants. Possible explanations for these findings and their possible relation to TRD are discussed.

Cognitive therapy for anxious depression in STAR(*) D: what have we learned?

BACKGROUND

Anxious depression, defined as MDD with high levels of anxiety symptoms, has been associated with lower rates of antidepressant response and remission as well as greater chronicity, suicidality and antidepressant side-effect burden. The primary aim of this study was to assess the effectiveness of cognitive therapy (CT) alone or in combination with medications for anxious versus non-anxious depression.

METHODS

We assessed the STAR(⁎)D study participants who were partial or non-responders to citalopram. Subjects were then either switched (n=696) to a new antidepressant or to CT alone, or they were kept on citalopram and augmented (n=577) with another antidepressant or CT. We compared response and remission rates, across treatment conditions, between those who met criteria for anxious depression and those who did not.

RESULTS

Those with anxious depression had significantly lower remission rates based on the QIDS, whether assigned to switch or augmentation, compared to those with non-anxious depression. Those with anxious depression, compared to those without, had significantly lower response rates based on the QIDS only in the switch group. There was no significant interaction between anxious depression and treatment assignment.

LIMITATIONS

Limitations include the use of citalopram as the only Level 1 pharmacotherapy and medication augmentation option, the relatively small size of the CT arms, use of depression-focused CT rather than anxiety-focused CT, and focus on acute treatment outcomes.

CONCLUSIONS

Individuals with anxious depression appear to experience higher risk of poorer outcome following pharmacotherapy and/or CT after an initial course of citalopram and continued efforts to target this challenging form of depression are needed.

Prediction of remission of depression with clinical variables, neuropsychological performance, and serotonergic/dopaminergic gene polymorphisms

OBJECTIVE

The aim of our work is to study the possible role of clinical variables, neuropsychological performance, and the 5HTTLPR, rs25531, and val108/58Met COMT polymorphisms on the prediction of depression remission after 12 weeks' treatment with fluoxetine. These variables have been studied as potential predictors of depression remission, but they present poor prognostic sensitivity and specificity by themselves.

METHODS

Seventy-two depressed patients were genotyped according to the aforementioned polymorphisms and were clinically and neuropsychologically assessed before a 12-week fluxetine treatment.

RESULTS

Only the La allele of rs25531 polymorphism and the GG and AA forms of the val 108/158 Met polymorphism predict major depressive disorder remission after 12 weeks' treatment with fluoxetine. None of the clinical and neuropsychological variables studied predicted remission.

CONCLUSIONS

Our results suggest that clinical and neuropsychological variables can initially predict early response to fluoxetine and mask the predictive role of genetic variables; but in remission, where clinical and neuropsychological symptoms associated with depression tend to disappear thanks to the treatment administered, the polymorphisms studied are the only variables in our model capable of predicting remission. However, placebo effects that are difficult to control require cautious interpretation of the results.

Correlates and outcomes of depressed out-patients with greater and fewer anxious symptoms: a CO-MED report

The objective of this paper was to determine whether the presence of more vs. fewer anxious symptom features, at baseline, are associated with other clinical features and treatment outcomes in out-patients with major depressive disorder (MDD). This single-blind, randomized trial enrolled 665 MDD out-patients to compare the efficacy of two antidepressant medication combinations against escitalopram after 12-wk acute treatment and follow-up (total 28 wk). The sample was divided into those with greater (vs. fewer) anxiety features using the anxiety/somatization subscale of the baseline 17-item Hamilton Rating Scale for Depression. Baseline sociodemographic and clinical features, treatment features and outcomes compared these two groups. Overall, 74.7% of participants met the threshold for 'anxious features'. They were more likely to be female, have other concurrent anxiety disorders, more severe depression, more lethargic and melancholic features and poorer cognitive and physical functioning, quality of life and work and social adjustment. In acute treatment, participants with anxious features received comparatively higher doses of mirtazapine and venlafaxine and reported more side-effects. The groups with and without anxious features did not differ in treatment outcomes and side-effect burden. Despite being associated with a distinct clinical profile, baseline anxious features were not clinically useful in predicting acute treatment outcomes or differential treatment response.

Efficacy versus effectiveness: a direct comparison of the outcome of treatment for mild to moderate depression in randomized controlled trials and daily practice

BACKGROUND

Results from randomized controlled trials (RCTs) are considered to give the most reliable information on treatment outcome (efficacy). Yet, the generalizability of efficacy results to daily practice (effectiveness) might be diminished by the design of RCTs. The STAR*D trial approached daily practice as much as possible, but still has some properties of an RCT. In this study, we compare results from treatment of major depressive disorder (MDD) in routine clinical practice to those of RCTs and STAR*D.

METHODS

Effectiveness in routine clinical practice was compared with efficacy results from 15 meta-analyses on antidepressant, psychotherapeutic and combination treatment and results from STAR*D. Data on daily practice patients and treatments were derived from a routine outcome monitoring (ROM) system. Treatment outcome was defined as proportion of remitters (MADRS ≤10) and within-group effect size.

RESULTS

From ROM, 598 patients suffering from a MDD episode according to the MINI-plus were included. Remission percentages were lower in routine practice than in meta-analyses for all treatment modalities (32 vs.40-74%). Differences were less explicit for antidepressants (21 vs. 34-47%) than for individual psychotherapy (27 vs. 34-58%; effect size 0.85 vs. 1.71) and combination therapy (21 vs. 45-63%), since only 60% of the meta-analyses for antidepressants showed significant differences with ROM, while for psychotherapy and combination treatment almost all meta-analyses showed significant differences. No differences in effectiveness were found between routine practice and STAR*D (antidepressants 27 vs. 28%; individual psychotherapy 27 vs. 25%; combination treatment 21 vs. 23%, respectively).

CONCLUSIONS

Effectiveness of treatment for mild-to-moderate MDD in daily practice is similar to STAR*D and significantly lower than efficacy results from RCTs.

Surrogate markers of treatment outcome in major depressive disorder

Major depressive disorder (MDD) is a common medical illness affecting millions worldwide. Despite their widespread use since the 1950s and 1960s, the 'downstream' mechanism by which antidepressants ultimately exert their therapeutic effects remains elusive. In addition, except for a few exceptions such as episode severity and the presence of comorbid Axis-I or Axis-III disorders, biological or clinical characteristics which can accurately quantify the risk of poor treatment outcome are lacking, as are factors which could help patients and clinicians select treatment options that would result in superior outcome. The identification of such markers, termed 'surrogate' markers, could help shed further insights into what constitutes illness and recovery, help identify molecular targets for the development of future antidepressants, and lead the way to the design and refinement of a personalized medicine treatment model for MDD. In the following text, several major areas ('leads') where evidence exists regarding the presence of surrogate markers of efficacy outcome in MDD will be briefly reviewed. Leads include evidence from the role of demographic and clinical factors as surrogate markers, to the role of various biological markers including genotype, brain functional imaging, electroencephalography, dichotic listening, and molecular biology and immunology. The purpose of this work is to focus selectively on areas where there have been findings, as opposed to conducting an exhaustive literature review of studies which have failed to yield any significant breakthrough in our knowledge.

Extended release quetiapine fumarate in major depressive disorder: analysis in patients with anxious depression

BACKGROUND

A pooled analysis was performed on data from two studies evaluating the efficacy of once-daily extended-release quetiapine fumarate (quetiapine XR) monotherapy for patients with major depressive disorder. Through these analyses (based on Hamilton Rating Scale for Depression (HAM-D) and Hamilton Rating Scale for Anxiety (HAM-A) measures), we aim to further evaluate the efficacy of quetiapine XR in depressed patients with high levels of anxiety symptoms.

METHODS

Secondary analyses were conducted of pooled individual patient data from two 8-week (6-week randomized phase, 2-week drug discontinuation phase), double-blind, placebo-controlled studies of quetiapine XR (50-300 mg/day). Outcomes included change from randomization at Week 6 in Montgomery Åsberg Depression Rating Scale (MADRS) total score for patients with anxious and nonanxious depression.

RESULTS

Of 968 patients included in the analysis, 788 (81.4%) were classified as anxious depressed (defined as HAM-D anxiety/somatization factor score ≥ 7) and 180 (18.6%) were nonanxious. For patients with anxious depression and nonanxious depression, statistically significant differences versus placebo in MADRS total score were recorded for quetiapine XR 150 mg/day (-3.24, P < .001 and -4.82, P < .01, respectively) and 300 mg/day (-3.57, P < .001 and -3.39, P < .05, respectively) at Week 6. In the second analysis using an alternate definition of anxious depression (baseline HAM-A total score ≥ 20), quetiapine XR 150 and 300 mg/day resulted in significant differences versus placebo in MADRS total score reduction in patients with high and lower levels of anxiety. The adverse event (AE) profile was similar irrespective of baseline anxiety levels, although patients with anxious depression reported a somewhat greater incidence of AEs.

CONCLUSION

Quetiapine XR monotherapy improved symptoms of depression in patients with higher and lower levels of anxiety.

Outcomes of acute phase cognitive therapy in outpatients with anxious versus nonanxious depression

OBJECTIVE

Compared to nonanxious depressed patients, anxious depressed patients respond less to pharmacotherapy, prompting consideration of alternate treatments. Based on the transdiagnostic principles of cognitive therapy (CT), we predicted that anxious depressed patients would respond as well to CT as nonanxious depressed patients.

METHOD

Adults (n = 523) with recurrent major depressive disorder received 12-14 weeks of CT as part of the Continuation Phase Cognitive Therapy Relapse Prevention Trial. Anxious depressed patients (n = 264; 50.4%) were compared to nonanxious depressed patients (n = 259; 49.6%) on demographic variables, initial severity, attrition, and rates and patterns of response and remission.

RESULTS

Anxious depressed patients presented with greater illness severity and had significantly lower response (55.3 vs. 68.3%) and remission rates (26.9 vs. 40.2%) based on clinician-administered measures. By contrast, smaller between-group differences for attrition, and for response (59.1 vs. 64.9%) and remission (41.7 vs. 48.7%) rates on self-report measures were not significant. Further, anxious depressed patients had greater speed of improvement on self-reported anxiety symptom severity and clinician-rated depressive and anxiety symptom severity measures.

CONCLUSION

Consistent with prior reports, anxious depressed patients presented with greater severity and, following CT, had lower response and remission rates on clinician-administered scales. However, anxious depressed patients improved more rapidly and response and remission rates on self-report measures were not significantly different from nonanxious depressed patients. Our findings suggest that anxious depressed patients may simply need additional time or more CT sessions to reach outcomes fully comparable to those of less anxious patients.

What are the clinical implications of new onset or worsening anxiety during the first two weeks of SSRI treatment for depression?

OBJECTIVE

To evaluate the prevalence of new onset or worsening of anxiety symptoms, as well as their clinical implications, during the first 2 weeks of Selective Serotonin Reuptake Inhibitor (SSRI) pharmacotherapy for depression.

METHOD

Adult outpatients with nonpsychotic major depressive disorder were enrolled in an 8-week acute phase SSRI treatment trial at 15 clinical sites across the United States. Worsening anxiety was defined as a greater than 2-point increase on the Beck Anxiety Inventory (BAI) between baseline and Week 2. New onset of anxiety symptoms was ascribed when the BAI baseline rating was 0 and the Week 2 value was greater or equal to 2 points on the BAI.

RESULTS

Overall, after 2 weeks of treatment, 48.8% (98 of 201 participants) reported improvement in anxiety symptoms, 36.3% (73 of 201) reported minimal symptom change, and 14.9% (30 of 201) reported worsening of anxiety symptoms. No association was found between change in anxiety symptoms within the first 2 weeks and change in depressive symptoms or remission at the end of 8 weeks of treatment. For participants with clinically meaningful anxiety symptoms at baseline, however, worsening of anxiety during the first 2 weeks of treatment was associated with worsening depressive symptoms by 8 weeks (P = .054).

CONCLUSIONS

The trajectory of anxiety symptom change early in SSRI treatment is an important indicator of eventual outcome for outpatients with major depression and baseline anxiety symptoms.