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Zhou J, Zhou J, Feng Y, Feng L, Xiao L, Chen X, Feng Z, Yang J, Wang G. The novel subtype of major depressive disorder characterized by somatic symptoms is associated with poor treatment efficacy and prognosis: A data-driven cluster analysis of a prospective cohort in China. J Affect Disord 2024; 347:576-583. [PMID: 38065479 DOI: 10.1016/j.jad.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/15/2023] [Accepted: 12/02/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND There is not yet a valid and evidence-based system to classify patients with MDD into more homogeneous subtypes based on their clinical features. This study aims to identify symptom-based subtypes of MDD and investigate whether the treatment outcomes of those subtypes would be different. METHOD The cohort was established at 12 densely populated cities of China. A total of 1487 patients were enrolled. All participants were 18-65 years old and diagnosed with MDD. Participants were followed up at baseline, weeks 4, 8, and 12, and months 4 and 6. K-means algorithm was used to cluster patients with MDD according to clinical symptoms. The network analysis was adopted to characterize and compare the symptom patterns in the clusters. We also examined the associations between the clusters and the clinical outcomes. RESULTS The optimal number of the clusters was determined to be 2. Each cluster's maximum Jaccard Co-efficient was calculated to be >0.5 (cluster1 = 0.53, cluster 2 = 0.67). The symptom "depressed mood" and some other affective symptoms were the most prominent in cluster 1. Somatic symptoms, such as weight loss and general somatic symptoms, had the greatest expected influence in cluster 2. Compared with the response rates of the patients in the "somatic cluster", those of the patients in the "affective cluster" were significantly higher (P < 0.05). CONCLUSIONS Patients with MDD might be classified into two symptom-based subtypes featured with affective symptoms or somatic symptoms. The treatment efficacy and prognosis of the subtype featured with somatic symptoms may be worse.
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Affiliation(s)
- Jingjing Zhou
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jia Zhou
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Yuan Feng
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Lei Feng
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Le Xiao
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Xu Chen
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Zizhao Feng
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jian Yang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Gang Wang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
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Shi J, Wang X, Zhao N, Kang C, Yang L, Zheng Y, Liu J, Feng L, Zhu X, Ma C, Wu W, Wang G, Hu J. Sex differences in residual somatic symptoms in patients with first-episode depression after acute-phase treatment. BMC Psychiatry 2023; 23:119. [PMID: 36814241 PMCID: PMC9948378 DOI: 10.1186/s12888-023-04612-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/15/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Residual somatic symptoms (RSS) are common in depressed patients, predicting treatment effectiveness. However, sex differences in RSS have received little systematic study. This study was conducted to compare sex differences of RSS in patients with first-episode depression (FED). METHODS Nine hundred eighty-two patients with FED were selected and treated for 8 to 12 weeks. We evaluated the subjects' socio-demographic characteristics and residual depressive symptoms. Using the Patient Health Questionnaire-15 (PHQ-15) scale to assess residual somatic symptoms, the Sheehan Disability Scale (SDS) for the assessment of patients' function, the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) for quality of life. RESULTS The incidence of RSS with FED was 46.4%. For patients with residual symptoms, the age and age of onset in females were higher than males, but males had more years of education than females. The degree of "stomach pain" in females was more severe than in males, while "trouble sleeping" in males was more severe than that in females. Multiple regression analysis showed that the total Q-LES-Q-SF score was an independent influencing factor of RSS in both males and females, while the total SDS score only affected female RSS. CONCLUSIONS The prevalence of RSS in FED after acute-phase treatment is high. The symptom of "stomachache" is more pronounced in females, while "trouble sleeping" is more severe in males. Quality of life plays an essential role in RSS in both genders. Thus, sex needs to be considered when assessing the relationship between RSS and therapeutic effect in depression.
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Affiliation(s)
- Jingjing Shi
- grid.412596.d0000 0004 1797 9737Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001 China
| | - Xiaohong Wang
- grid.412596.d0000 0004 1797 9737Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001 China
| | - Na Zhao
- grid.412596.d0000 0004 1797 9737Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001 China
| | - Chuanyi Kang
- grid.412596.d0000 0004 1797 9737Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001 China
| | - Liying Yang
- grid.412596.d0000 0004 1797 9737Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001 China
| | - Yue Zheng
- grid.11135.370000 0001 2256 9319Peking University Institute of Mental Health (Sixth Hospital), Beijing, China ,grid.11135.370000 0001 2256 9319National Clinical Research Center for Mental Disorders & NHC Key Laboratory of Mental Health, Peking University, Beijing, China
| | - Jiacheng Liu
- grid.412596.d0000 0004 1797 9737Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001 China
| | - Lei Feng
- grid.24696.3f0000 0004 0369 153XThe National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Xuequan Zhu
- grid.24696.3f0000 0004 0369 153XThe National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Caina Ma
- Harbin First Specialized Hospital, Heilongjiang Province, Harbin, China
| | - Wenyuan Wu
- grid.412793.a0000 0004 1799 5032Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, China
| | - Gang Wang
- grid.24696.3f0000 0004 0369 153XThe National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Jian Hu
- Department of Psychiatry, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang DistrictHeilongjiang Province, Harbin, 150001, China.
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Zhou J, Zhou J, Feng L, Feng Y, Xiao L, Chen X, Yang J, Wang G. The associations between depressive symptoms, functional impairment, and quality of life, in patients with major depression: undirected and Bayesian network analyses. Psychol Med 2022; 53:1-13. [PMID: 36349712 PMCID: PMC10600944 DOI: 10.1017/s0033291722003385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 09/29/2022] [Accepted: 10/07/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Depressive symptoms, functional impairment, and decreased quality of life (QOL) are three important domains of major depressive disorder (MDD). However, the possible causal relationship between these factors has yet to be elucidated. Moreover, it is not known whether certain symptoms of MDD are more impairing than others. The network approach is a promising solution to these shortfalls. METHODS The baseline data of a multicenter prospective project conducted in 11 governances of China were analyzed. In total, 1385 patients with MDD were included. Depressive symptoms, functioning disability, and QOL were evaluated by the 17-item Hamilton Depression Rating Scale (HAMD-17), the Sheehan Disability Scale (SDS), and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). The network was estimated through the graphical Least Absolute Shrinkage and Selection Operator (LASSO) technique in combination with the directed acyclic graph. RESULTS Three centrality metrics of the graphical LASSO showed that social life dysfunction, QOL, and late insomnia exhibited the highest strength centrality. The network accuracy and stability were estimated to be robust and stable. The Bayesian network indicated that some depressive symptoms were directly associated with QOL, while other depressive symptoms showed an indirect association with QOL mediated by impaired function. Depressed mood was positioned at the highest level in the model and predicted the activation of functional impairment and anxiety. CONCLUSIONS Functional disability mediated the relationship between depressive symptoms and QOL. Family functionality and suicidal symptoms were directly related to QOL. Depressed mood played the predominant role in activating both anxiety symptom and functional impairment.
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Affiliation(s)
- Jia Zhou
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jingjing Zhou
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Lei Feng
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Yuan Feng
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Le Xiao
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Xu Chen
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jian Yang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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王 静, 袁 敏, 张 伟. [Changes and Prediction of Social Functional Disability and Quality of Life in Patients with Major Depressive Disorder over the Course of 1-Year Medication]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2022; 53:904-910. [PMID: 36224695 PMCID: PMC10408809 DOI: 10.12182/20220960509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 06/16/2023]
Abstract
Objective To investigate the changes in social function impairment and quality of life and their predictive factors in patients with major depressive disorder (MDD) over the course of 1-year drug treatment. Methods A total of 54 MDD patients were enrolled for the study. The 17-item Hamilton Rating Scale for Depression (HAMD-17, hereafter referred to simply as HAMD), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) were used to evaluate depressive symptoms, social functioning, and quality of life, respectively, at baseline (0), as well as 1 month (1 m), 2 months (2 m), 3 months (3 m), 6 months (6 m), 9 months (9 m), and 12 months (12 m) after medication started. The symptoms and the recovery of social function at different time points was analyzed, and correlation analysis and regression analysis were done to explore the influencing factors of functional recovery. Results Among the 54 MDD patients, 27 completed the 12-month follow-up, and 2 patients relapsed at 12 m. The total baseline score of SDS (SDS 0) in MDD patients was higher than that in healthy controls ( t=12.161, P<0.001), and the baseline score of Q-LES-Q-SF (Q-LES-Q-SF 0) was lower than that in the controls ( t=12.260, P<0.001). Comparison of the HAMD score, SDS total score and the factor scores, and Q-LES-Q-SF total scores of the MDD patients at different time points showed significant differences, presenting an F value of 65.987, 28.944, 23.589, 27.070 and 28.668, respectively (all P<0.001). HAMD 0 was negatively correlated with age. The HAMD score was positively correlated with SDS score of the same time point and negatively correlated with Q-LES-Q-SF score of the same time point. At 3 m, the change in HAMD score (HAMD 3 m-0) was positively correlated with the change in SDS score (SDS 3 m-0) and negatively correlated with the change in Q-LES-Q-SF score (Q-LES-Q 3 m-0). At 12 m, the change in HAMD score (HAMD 12 m-0) was positively correlated with the change in SDS score (SDS 12 m-0) and negatively correlated with the change in Q-LES-Q-SF score (Q-LES-Q 12 m-0). Regression analysis revealed that SDS 0 and Q-LES-Q 0 could be used to predict SDS 3 m-0, R 2=0.391, while SDS 0 and full-time employment status could be used to predict SDS 12 m-0, R 2=0.640. Q-LES-Q 0 could be used to predict Q-LES-Q 3 m-0, R 2=0.294, while Q-LES-Q 0 and full-time employment status could be used to predict Q-LES-Q 12 m-0, R 2=0.591. Conclusion Long-term regular medication can improve social dysfunction in patients with MDD and symptom relief is the basis for improvement of social function level and quality of life, while increasing employment saturability to some extent may help improve the long-term social function and quality of life.
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Affiliation(s)
- 静怡 王
- 四川大学华西医院 心理卫生中心 (成都 610041)Mental Health Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 敏兰 袁
- 四川大学华西医院 心理卫生中心 (成都 610041)Mental Health Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 伟 张
- 四川大学华西医院 心理卫生中心 (成都 610041)Mental Health Center, West China Hospital, Sichuan University, Chengdu 610041, China
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Kim HK, Zai G, Müller DJ, Husain MI, Lam RW, Frey BN, Soares CN, Parikh SV, Milev R, Foster JA, Turecki G, Farzan F, Mulsant BH, Kennedy SH, Tripathy SJ, Kloiber S. Identification of Endocannabinoid Predictors of Treatment Outcomes in Major Depressive Disorder: A Secondary Analysis of the First Canadian Biomarker Integration Network in Depression (CAN-BIND 1) Study. PHARMACOPSYCHIATRY 2022; 55:297-303. [PMID: 35793696 DOI: 10.1055/a-1872-0844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION An increasing number of studies are examining the link between the endocannabinoidome and major depressive disorder (MDD). We conducted an exploratory analysis of this system to identify potential markers of treatment outcomes. METHODS The dataset of the Canadian Biomarker Integration Network in Depression-1 study, consisting of 180 patients with MDD treated for eight weeks with escitalopram followed by eight weeks with escitalopram alone or augmented with aripiprazole was analyzed. Association between response Montgomery-Asberg Depression Rating Scale (MADRS; score reduction≥50%) or remission (MADRS score≤10) at weeks 8 and 16 and single nucleotide polymorphisms (SNPs), methylation, and mRNA levels of 33 endocannabinoid markers were examined. A standard genome-wide association studies protocol was used for identifying SNPs, and logistic regression was used to assess methylation and mRNA levels. RESULTS Lower methylation of CpG islands of the diacylglycerol lipase alpha gene (DAGLA) was associated with non-remission at week 16 (DAGLA; OR=0.337, p<0.003, q=0.050). Methylation of DAGLA was correlated with improvement in Clinical Global Impression (p=0.026), Quick Inventory of Depressive Symptomatology (p=0.010), and Snaith-Hamilton Pleasure scales (p=0.028). We did not find any association between SNPs or mRNA levels and treatment outcomes. DISCUSSION Methylation of DAGLA is a promising candidate as a marker of treatment outcomes for MDD and needs to be explored further.
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Affiliation(s)
- Helena K Kim
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Gwyneth Zai
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Daniel J Müller
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Muhammad I Husain
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.,Mood Disorders Program and Women's Health Concerns Clinic, St. Joseph's Healthcare, Hamilton, Canada
| | - Claudio N Soares
- Department of Psychiatry, Queen's university School of Medicine, Kingston, Canada
| | - Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, United States of America
| | - Roumen Milev
- Department of Psychiatry, Queen's university School of Medicine, Kingston, Canada.,Department of Psychiatry, Providence care, Kingston, Canada
| | - Jane A Foster
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Gustavo Turecki
- Douglas Institute, Department of Psychiatry, McGill University, Montreal, Canada
| | - Faranak Farzan
- eBrain Lab, School of Mechatronic Systems Engineering, Simon Fraser University, Surrey, Canada
| | - Benoit H Mulsant
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sidney H Kennedy
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Shreejoy J Tripathy
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Krembil Center for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
| | - Stefan Kloiber
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
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Benjet C, Kessler RC, Kazdin AE, Cuijpers P, Albor Y, Carrasco Tapias N, Contreras-Ibáñez CC, Durán González MS, Gildea SM, González N, Guerrero López JB, Luedtke A, Medina-Mora ME, Palacios J, Richards D, Salamanca-Sanabria A, Sampson NA. Study protocol for pragmatic trials of Internet-delivered guided and unguided cognitive behavior therapy for treating depression and anxiety in university students of two Latin American countries: the Yo Puedo Sentirme Bien study. Trials 2022; 23:450. [PMID: 35658942 PMCID: PMC9164185 DOI: 10.1186/s13063-022-06255-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 03/29/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are highly prevalent among university students and predict impaired college performance and later life role functioning. Yet most students do not receive treatment, especially in low-middle-income countries (LMICs). We aim to evaluate the effects of expanding treatment using scalable and inexpensive Internet-delivered transdiagnostic cognitive behavioral therapy (iCBT) among college students with symptoms of MDD and/or GAD in two LMICs in Latin America (Colombia and Mexico) and to investigate the feasibility of creating a precision treatment rule (PTR) to predict for whom iCBT is most effective. METHODS We will first carry out a multi-site randomized pragmatic clinical trial (N = 1500) of students seeking treatment at student mental health clinics in participating universities or responding to an email offering services. Students on wait lists for clinic services will be randomized to unguided iCBT (33%), guided iCBT (33%), and treatment as usual (TAU) (33%). iCBT will be provided immediately whereas TAU will be whenever a clinic appointment is available. Short-term aggregate effects will be assessed at 90 days and longer-term effects 12 months after randomization. We will use ensemble machine learning to predict heterogeneity of treatment effects of unguided versus guided iCBT versus TAU and develop a precision treatment rule (PTR) to optimize individual student outcome. We will then conduct a second and third trial with separate samples (n = 500 per arm), but with unequal allocation across two arms: 25% will be assigned to the treatment determined to yield optimal outcomes based on the PTR developed in the first trial (PTR for optimal short-term outcomes for Trial 2 and 12-month outcomes for Trial 3), whereas the remaining 75% will be assigned with equal allocation across all three treatment arms. DISCUSSION By collecting comprehensive baseline characteristics to evaluate heterogeneity of treatment effects, we will provide valuable and innovative information to optimize treatment effects and guide university mental health treatment planning. Such an effort could have enormous public-health implications for the region by increasing the reach of treatment, decreasing unmet need and clinic wait times, and serving as a model of evidence-based intervention planning and implementation. TRIAL STATUS IRB Approval of Protocol Version 1.0; June 3, 2020. Recruitment began on March 1, 2021. Recruitment is tentatively scheduled to be completed on May 30, 2024. TRIAL REGISTRATION ClinicalTrials.gov NCT04780542 . First submission date: February 28, 2021.
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Affiliation(s)
- Corina Benjet
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico.
| | - Ronald C Kessler
- Department of Health care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Yesica Albor
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | | | | | | | - Sarah M Gildea
- Department of Health care Policy, Harvard Medical School, Boston, MA, USA
| | - Noé González
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz and School of Psychology, UNAM, Mexico City, Mexico
| | | | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Maria Elena Medina-Mora
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz and School of Psychology, UNAM, Mexico City, Mexico
| | - Jorge Palacios
- SilverCloud Health, Dublin, Ireland
- E-mental Health Group, School of Psychology, University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Derek Richards
- SilverCloud Health, Dublin, Ireland
- E-mental Health Group, School of Psychology, University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Alicia Salamanca-Sanabria
- Future Health Technologies Programme, Campus for Research Excellence and Technological Enterprise, Singapore-ETH Centre, Singapore, Singapore
| | - Nancy A Sampson
- Department of Health care Policy, Harvard Medical School, Boston, MA, USA
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7
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Chow TK, Bowie CR, Morton M, Lalovic A, McInerney SJ, Rizvi SJ. Contributors of Functional Impairment in Major Depressive Disorder: a Biopsychosocial Approach. Curr Behav Neurosci Rep 2022. [DOI: 10.1007/s40473-022-00247-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Li VW, Morton E, Michalak EE, Tam EM, Levitt AJ, Levitan RD, Cheung A, Morehouse R, Ramasubbu R, Yatham LN, Lam RW. Functional outcomes with bright light in monotherapy and combined with fluoxetine in patients with major depressive disorder: Results from the LIFE-D trial. J Affect Disord 2022; 297:396-400. [PMID: 34699857 DOI: 10.1016/j.jad.2021.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/24/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Victor W Li
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada
| | - Emma Morton
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada
| | - Erin E Michalak
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada
| | - Edwin M Tam
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada
| | - Anthony J Levitt
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Amy Cheung
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Rachel Morehouse
- Department of Psychiatry, Dalhousie University, Saint John, NB, Canada
| | | | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada.
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9
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Kampalli SRNPK, Nemani A, Nadukuru N. Disability associated with premenstrual dysphoric disorder: A prospective study. ARCHIVES OF MENTAL HEALTH 2022. [DOI: 10.4103/amh.amh_110_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Zhou R, Chen J, Zhao G, Wang Z, Peng D, Xia W, Mao R, Xu J, Wang F, Zhang C, Wang Y, Yuan C, Su Y, Huang J, Yang T, Wang C, Cui L, Wang J, Palaniyappan L, Fang Y. Neural biomarker of functional disability in major depressive disorder: A structural neuroimaging study. Prog Neuropsychopharmacol Biol Psychiatry 2021; 111:110337. [PMID: 33905754 DOI: 10.1016/j.pnpbp.2021.110337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 04/08/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Most patients with the major depressive disorder (MDD) have varying degrees of impaired social functioning, and functional improvement often lags behind symptomatic improvement. However, it is still unclear if certain neurobiological factors underlie the deficits of social function in MDD. The aim of this study was to investigate the biomarkers of social function in MDD using structural magnetic resonance imaging (MRI). METHODS 3T anatomical MRI was obtained from 272 subjects including 46 high-functioning (high-SF, Sheehan Disability Scale (SDS) rating < 18) and 63 low-functioning (low-SF, SDS score ≥ 18) patients with MDD and 163 healthy controls (HC). Voxel-based morphometry (VBM) was employed to locate brain regions with grey matter (GM) volume differences in relation to social function in MDD. Regions showing GM differences in relation to social function at baseline were followed up longitudinally in a subset of 38 patients scanned after 12-week treatment. RESULTS Volume of right parahippocampal gyrus (rPHG) was significantly reduced in low-SF patients with MDD when compared to high-SF ones (FDR-corrected p < 0.05). Over 12 weeks of follow-up, though SF improved overall, the high and low-SF subgroups continued to differ in their SF, but had no progressive changes in PHG volume. LIMITATIONS Limited functional assessment, high drop-out rate and median-based grouping method. CONCLUSIONS Greater GM volume (GMV) of the rPHG may mark better social function in patients with MDD.
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Affiliation(s)
- Rubai Zhou
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; Department of EEG & Neuroimaging, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; Robarts Research Institute& The Brain and Mind Institute, Western University, London, ON, Canada
| | - Jun Chen
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China; Shanghai Key Laboratory of Psychotic disorders, Shanghai 201108, China
| | - Guoqing Zhao
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; Department of Psychology, Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Zuowei Wang
- Hongkou District Mental Health Center of Shanghai, Shanghai 200080, China
| | - Daihui Peng
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Weiping Xia
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; Department of Medical Psychology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Ruizhi Mao
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Jingjing Xu
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Fan Wang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Chen Zhang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Yong Wang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Chengmei Yuan
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Yousong Su
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Jia Huang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Tao Yang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Chenglei Wang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Lvchun Cui
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Jijun Wang
- Shanghai Key Laboratory of Psychotic disorders, Shanghai 201108, China; Department of EEG & Neuroimaging, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders, Ministry of Education, Shanghai 200030, China; Brain Science and Technology Research Center, Shanghai Jiao Tong University, Shanghai, China
| | - Lena Palaniyappan
- Robarts Research Institute& The Brain and Mind Institute, Western University, London, ON, Canada; Department of Psychiatry, Western University, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada.
| | - Yiru Fang
- Clinical Research Center and Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China; CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China; Shanghai Key Laboratory of Psychotic disorders, Shanghai 201108, China.
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11
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Lu J, Xu X, Huang Y, Li T, Ma C, Xu G, Yin H, Xu X, Ma Y, Wang L, Huang Z, Yan Y, Wang B, Xiao S, Zhou L, Li L, Zhang Y, Chen H, Zhang T, Yan J, Ding H, Yu Y, Kou C, Shen Z, Jiang L, Wang Z, Sun X, Xu Y, He Y, Guo W, Jiang L, Li S, Pan W, Wu Y, Li G, Jia F, Shi J, Shen Z, Zhang N. Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological study. Lancet Psychiatry 2021; 8:981-990. [PMID: 34559991 DOI: 10.1016/s2215-0366(21)00251-0] [Citation(s) in RCA: 241] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/21/2021] [Accepted: 06/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND In China, depressive disorders have been estimated to be the second leading cause of years lived with disability. However, nationally representative epidemiological data for depressive disorders, in particular use of mental health services by adults with these disorders, are unavailable in China. The present study, part of the China Mental Health Survey, 2012-15, aims to describe the socioeconomic characteristics and the use of mental health services in people with depressive disorders in China. METHODS The China Mental Health Survey was a cross-sectional epidemiological survey of mental disorders in a multistage clustered-area probability sample of adults of Chinese nationality (≥18 years) from 157 nationwide representative population-based disease surveillance points in 31 provinces across China. Trained investigators interviewed the participants with the Composite International Diagnostic Interview 3.0 to ascertain the presence of lifetime and 12-month depressive disorders according to DSM-IV criteria, including major depressive disorder, dysthymic disorder, and depressive disorder not otherwise specified. Participants with 12-month depressive disorders were asked whether they received any treatment for their emotional problems during the past 12 months and, if so, the specific types of treatment providers. The Sheehan Disability Scale (SDS) was used to assess impairments associated with 12-month depressive symptoms. Data-quality control procedures included logic check by computers, sequential recording check, and phone-call check by the quality controllers, and reinterview check by the psychiatrists. Data were weighted according to the age-sex-residence distribution data from China's 2010 census population survey to adjust for differential probabilities of selection and differential response, as well as to post-stratify the sample to match the population distribution. FINDINGS 28 140 respondents (12 537 [44·6%] men and 15 603 [55·4%] women) completed the survey between July 22, 2013, and March 5, 2015. Ethnicity data (Han or non-Han) were collected for only a subsample. Prevalence of any depressive disorders was higher in women than men (lifetime prevalence odds ratio [OR] 1·44 [95% CI 1·20-1·72] and 12-month prevalence OR 1·41 [1·12-1·78]), in unemployed people than employed people (lifetime OR 2·38 [95% CI 1·68-3·38] and 12-month OR 2·80 [95% CI 1·88-4·18]), and in people who were separated, widowed, or divorced compared with those who were married or cohabiting (lifetime OR 1·87 [95% CI 1·39-2·51] and 12-month OR 1·85 [95% CI 1·40-2·46]). Overall, 574 (weighted % 75·9%) of 744 people with 12-month depressive disorders had role impairment of any SDS domain: 439 (83·6%) of 534 respondents with major depressive disorder, 207 (79·8%) of 254 respondents with dysthymic disorder, and 122 (59·9%) of 189 respondents with depressive disorder not otherwise specified. Only an estimated 84 (weighted % 9·5%) of 1007 participants with 12-month depressive disorders were treated in any treatment sector: 38 (3·6%) in speciality mental health, 20 (1·5%) in general medical, two (0·3%) in human services, and 21 (2·7%) in complementary and alternative medicine. Only 12 (0·5%) of 1007 participants with depressive disorders were treated adequately. INTERPRETATION Depressive disorders in China were more prevalent in women than men, unemployed people than employed, and those who were separated, widowed, or divorced than people who were married or cohabiting. Most people with depressive disorders reported social impairment. Treatment rates were very low, and few people received adequate treatment. National programmes are needed to remove barriers to availability, accessibility, and acceptability of care for depression in China. FUNDING National Health Commission and Ministry of Science and Technology of People's Republic of China. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Jin Lu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiufeng Xu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China; The Fourth People's Hospital in Urumqi, Urumqi, China
| | - Yueqin Huang
- Institute of Mental Health, Peking University Sixth Hospital, National Clinical Research Center for Mental Disorders & Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing, China.
| | - Tao Li
- Mental Health Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Chao Ma
- Institute of Mental Health, Peking University Sixth Hospital, National Clinical Research Center for Mental Disorders & Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing, China
| | | | | | - Xiangdong Xu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China; The Fourth People's Hospital in Urumqi, Urumqi, China
| | - Yanjuan Ma
- The Fourth People's Hospital in Urumqi, Urumqi, China
| | - Limin Wang
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhengjing Huang
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yongping Yan
- Department of Epidemiology, the Fourth Military Medical University, Xi'an, China
| | - Bo Wang
- Department of Epidemiology, the Fourth Military Medical University, Xi'an, China
| | - Shuiyuan Xiao
- Department of Social Medicine and Health Management, School of Public Health, Central South University, Changsha, China
| | - Liang Zhou
- Department of Social Medicine and Health Management, School of Public Health, Central South University, Changsha, China
| | - Lingjiang Li
- Mental Health Institute, the Second Xiangya Hospital, Central South University, Changsha, China
| | - Yan Zhang
- Mental Health Institute, the Second Xiangya Hospital, Central South University, Changsha, China
| | - Hongguang Chen
- Institute of Mental Health, Peking University Sixth Hospital, National Clinical Research Center for Mental Disorders & Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing, China
| | - TingTing Zhang
- Institute of Mental Health, Peking University Sixth Hospital, National Clinical Research Center for Mental Disorders & Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing, China
| | - Jie Yan
- Institute of Social Science Survey, Peking University, Beijing, China
| | - Hua Ding
- Institute of Social Science Survey, Peking University, Beijing, China
| | - Yaqin Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Changgui Kou
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Zonglin Shen
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Linling Jiang
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China; Mental Health Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhizhong Wang
- Department of Epidemiology and Statistics, School of Public Health, Ningxia Medical University, Yinchuan, China
| | - Xian Sun
- Department of Epidemiology and Statistics, School of Public Health, Ningxia Medical University, Yinchuan, China
| | - Yifeng Xu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanling He
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanjun Guo
- Mental Health Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Lijun Jiang
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China; Mental Health Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Shengyan Li
- The Third People's Hospital of Qinghai Province, Xining, Qinghai, China
| | - Wen Pan
- Suzhou Psychiatric Hospital, The Affiliated Guangji Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yue Wu
- Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Guohua Li
- Chifeng Anding Hospital, Chifeng, Inner Mongolia, China
| | - Fujun Jia
- Guangdong Mental Health Center, Guangzhou, Guangdong, China
| | - Jianfei Shi
- Department of Psychiatry, Hangzhou Seventh People's Hospital, Hangzhou, Zhejiang, China
| | - Zhongxia Shen
- The Third People's Hospital of Huzhou, Huzhou, Zhejiang, China
| | - Ning Zhang
- Nanjing Brain Hospital, affiliated to Nanjing Medical University, Nanjing, Jiangsu, China
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12
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Cao B, Xu L, Chen Y, Wang D, Lee Y, Rosenblat JD, Gao X, Zhan S, Sun F, McIntyre RS. Comparative efficacy of pharmacological treatments on measures of self-rated functional outcomes using the Sheehan Disability Scale in patients with major depressive disorder: a systematic review and network meta-analysis. CNS Spectr 2021:1-9. [PMID: 33583460 DOI: 10.1017/s1092852921000171] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE More than 50% patients with major depressive disorder (MDD) have severe functional impairment. The restoration of patient functioning is a critical therapeutic goal among patients with MDD. We conducted a systematic review and network meta-analysis to evaluate the efficacy of pharmacological treatments on self-rated functional outcomes using the Sheehan Disability Scale in adults with MDD in randomized clinical trials. METHODS PubMed, EMBASE, PsycINFO, Cochrane Library, and ClinicalTrials.gov were searched from inception to December 10, 2019. Summary statistics are reported as weighted mean differences with 95% confidence intervals. Interventions were ranked using the surface under the cumulative ranking probabilities. RESULTS We included 42 randomized controlled trials (RCTs) (n = 18 998) evaluating the efficacy of 13 different pharmacological treatments on functional outcomes, as measured by the Sheehan Disability Scale (SDS). Duloxetine was the most effective pharmacological agent on functional outcomes, followed by (ranked by efficacy): paroxetine, levomilnacipran, venlafaxine, quetiapine, desvenlafaxine, agomelatine, escitalopram, amitriptyline, bupropion, sertraline, vortioxetine, and fluoxetine. Serotonin and norepinephrine reuptake inhibitors were more effective than other drug classes. Additionally, the comparison-adjusted funnel plot suggested the publication bias between small and large studies was relatively low. CONCLUSIONS Our results indicate that there may be differences across antidepressant agents and classes with respect to self-reported functional outcomes. Validation and replication of these findings in large-scale RCTs are warranted. Our research results will be clinically useful for guiding psychiatrists in treating patients with MDD and functional impairment. PROSPERO registration number CRD42018116663.
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Affiliation(s)
- Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, China
- National Demonstration Center for Experimental Psychology Education, Southwest University, Chongqing, China
| | - Lu Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing100191, China
| | - Yan Chen
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, Canada
| | | | - Yena Lee
- Mood Disorders Psychopharmacology Unit, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Xiao Gao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, China
- National Demonstration Center for Experimental Psychology Education, Southwest University, Chongqing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing100191, China
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Feng Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing100191, China
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
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13
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Zubcevik N, Mao C, Wang QM, Bose EL, Octavien RN, Crandell D, Wood LJ. Symptom Clusters and Functional Impairment in Individuals Treated for Lyme Borreliosis. Front Med (Lausanne) 2020; 7:464. [PMID: 32974369 PMCID: PMC7472530 DOI: 10.3389/fmed.2020.00464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/13/2020] [Indexed: 11/17/2022] Open
Abstract
Context: Persistent fatigue, pain, and neurocognitive impairment are common in individuals following treatment for Lyme borreliosis (LB). Poor sleep, depression, visual disturbance, and sensory neuropathies have also been reported. The cause of these symptoms is unclear, and widely accepted effective treatment strategies are lacking. Objectives: To identify symptom clusters in people with persistent symptoms previously treated for LB and to examine the relationship between symptom severity and perceived disability. Methods: This was a retrospective chart review of individuals with a history of treatment of LB referred to The Dean Center for Tick-Borne Illness at Spaulding Rehabilitation Hospital between 2015 and 2018 (n = 270) because of persistent symptoms. Symptoms and functional impairment were collected using the General Symptom Questionnaire-30 (GSQ-30), and the Sheehan Disability Scale. Clinical tests were conducted to evaluate for tick-borne co-infections and to rule out medical disorders that could mimic LB symptomatology. Exploratory factor analysis was performed to identify symptom clusters. Results: Five symptom clusters were identified. Each cluster was assigned a name to reflect the possible underlying etiology and was based on the majority of the symptoms in the cluster: the neuropathy symptom cluster, sleep-fatigue symptom cluster, migraine symptom cluster, cognitive symptom cluster, and mood symptom cluster. Symptom severity for each symptom cluster was positively associated with global functional impairment (p < 0.001). Conclusion: Identifying the interrelationship between symptoms in post-treatment LB in a cluster can aid in the identification of the etiological basis of these symptoms and could lead to more effective symptom management strategies. Key Message: This article describes symptom clusters in individuals with a history of Lyme borreliosis. Five clusters were identified: sleep-fatigue, neuropathy, migraine-like, cognition, and mood clusters. Identifying the interrelationship between symptoms in each of the identified clusters could aid in more effective symptom management through identifying triggering symptoms or an underlying etiology.
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Affiliation(s)
- Nevena Zubcevik
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Invisible International, Cambridge, MA, United States
| | - Charlotte Mao
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States.,Massachusetts General Hospital, Department of Pediatric Infectious Diseases, Boston, MA, United States
| | - Qing Mei Wang
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Stroke Biological Recovery Laboratory, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Eliezer L Bose
- Stroke Biological Recovery Laboratory, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Rose Nadlyne Octavien
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - David Crandell
- The Dean Center for Tickborne Illness, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Lisa J Wood
- Massachusetts General Hospital, Institute for Health Professions, School of Nursing, Charlestown, MA, United States.,William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, United States
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14
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Zeljic K, Zhang Y, Qiu X, Chen X, Gong H, Jin H, Zhang C, Storch EA. An Evaluation of the Psychometric Properties of the Sheehan Disability Scale in a Chinese Psychotherapy-Seeking Sample. J Cogn Psychother 2020; 34:58-69. [PMID: 32701476 DOI: 10.1891/0889-8391.34.1.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although the Sheehan Disability Scale (SDS) is one of the most extensively used and tested disability measurements, there has only been one psychometric evaluation of its properties in a Chinese-speaking population. Here, we provide a comprehensive psychometric assessment of the scale in 465 Mandarin-speakers who were accessing information online regarding psychotherapy. Principal component analysis and subsequent confirmatory factor analysis indicated that the SDS is one-dimensional (normed fit index = 0.976, non-normed fit index = 0.97, comparative fit index = 0.98, goodness-of-fit index = 0.967, standardized root mean-square residual = 0.023, root mean-square error of approximation = 0.149). The SDS exhibited excellent internal consistency (α = .89) and moderate test-retest reliability when readministered approximately 8 days later (intraclass correlation coefficient = 0.55). Convergent validity was demonstrated by strong relationships with other measures of functional impairment (FI), while divergent validity was evidenced by fair correlation with a treatment ambivalence measure. Known-groups validity analyses showed that high FI was associated with significantly higher clinical scores of anxiety, depression, and obsessive-compulsive symptoms. Regression analysis indicated that the Depression Anxiety Stress Scale-21 score accounted for 37.6% of variance in FI. Overall, these findings support the reliability and validity of the SDS when used in Chinese treatment-seeking individuals, as well its usefulness as an online screening tool of FI.
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Affiliation(s)
- Kristina Zeljic
- Institute of Neuroscience, Shanghai Institute for Biological Sciences, Shanghai, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Yingying Zhang
- Ruijin hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xian Qiu
- Ruijin hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xi Chen
- Jiandanxinli Co. Ltd, Beijing, China
| | - Hengfen Gong
- Pudong District Mental Health Center, Shanghai, China
| | - Haiyan Jin
- Ruijin Hospital, Shanghai Jiao Tong University School, Shanghai, China
| | - ChenCheng Zhang
- Ruijin hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences.,Baylor College of Medicine
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15
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Zhong BL, Xu YM, Xie WX, Lu J. Frequent nightmares in Chinese patients undergoing methadone maintenance therapy: prevalence, correlates, and their association with functional impairment. Neuropsychiatr Dis Treat 2019; 15:2063-2072. [PMID: 31410010 PMCID: PMC6646172 DOI: 10.2147/ndt.s202813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/02/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Nightmares are associated with many negative health outcomes; however, little is known about the characteristics of nightmares in heroin-dependent patients (HDPs). This study examined the prevalence and correlates of frequent nightmares (FNs) and their association with functional impairment in Chinese patients undergoing methadone maintenance therapy (MMT). PATIENTS AND METHODS In total, 603 Chinese HDPs from three MMT clinics in Wuhan, China, completed this survey. FNs were defined as reporting nightmares at least once a week. The Sheehan Disability Scale (ShDS) was used to assess the severity of functional impairment of patients. A standardized questionnaire was used to collect data on socio-demographics, drug use characteristics, physical health, mental health, and insomnia. RESULTS The prevalence of FNs in Chinese HDPs receiving MMT was 25.9%. Factors significantly associated with nightmares among MMT HDPs included an educational attainment of senior high school and above (OR=2.73, P<0.001), unemployment (OR=3.16, P<0.001), a history of re-education through forced labor (OR=3.14, P<0.001), injecting heroin before MMT (OR=3.62, P=0.002), a high dose of methadone (>70 mg/day) (OR=2.03, P=0.006), use of hypnotics (OR=1.91, P=0.044), the presence of hepatitis B virus core antibody (OR=4.63, P<0.001), pain (OR=3.20, P<0.001), anxiety (OR=2.06, P=0.039), and insomnia (OR=5.75, P<0.001). After controlling for potential confounders, nightmares were still significantly associated with a higher ShDS score (β=2.718, P=0.006). CONCLUSION FNs are prevalent among Chinese HDPs receiving MMT and significantly associated with functional impairment. Nightmares are a clinically relevant phenomenon in Chinese MMT clinics, which deserves more clinical and research attention.
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Affiliation(s)
- Bao-Liang Zhong
- Research Center for Psychological and Health Sciences, China University of Geosciences, Wuhan, Hubei Province, People's Republic of China.,Affiliated Wuhan Mental Health Center, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, Hubei Province, People's Republic of China
| | - Yan-Min Xu
- Affiliated Wuhan Mental Health Center, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, Hubei Province, People's Republic of China
| | - Wu-Xiang Xie
- Peking University Clinical Research Institute, Peking University Health Science Center , Beijing, People's Republic of China
| | - Jin Lu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, People's Republic of China
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16
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Wang G, You X, Wang X, Xu X, Bai L, Xie J, Yao Z, Yi Q, Ma J, Wang J, Zhuo J, Hu C. Safety and effectiveness of escitalopram in an 8-week open study in Chinese patients with depression and anxiety. Neuropsychiatr Dis Treat 2018; 14:2087-2097. [PMID: 30147321 PMCID: PMC6097511 DOI: 10.2147/ndt.s164673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Anxiety symptoms usually worsen depression and functional impairment. The present study was aimed to evaluate the impact of escitalopram on social function and quality of life in major depressive disorder (MDD) patients with anxiety symptoms. PATIENTS AND METHODS Adult MDD patients with functional impairment (Sheehan Disability Scale [SDS] score ≥9) and anxiety symptoms (Hamilton Anxiety Rating Scale [HAM-A] score ≥14) received escitalopram (10-20 mg/day) for 8 weeks. Symptom status was assessed by SDS, Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form, Montgomery-Åsberg Depression Rating Scale (MADRS), HAM-A, and Quick Inventory of Depressive Symptomatology-Self Report scales. Safety was evaluated by treatment-emergent adverse events (TEAEs). RESULTS Overall, 208 (79.7%) of 261 enrolled patients completed the 8-week treatment. Mean (SD) SDS and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form total scores were 17.4 (5.87) and 39.3 (14.43) at baseline, which improved to 7.6 (6.71) and 61.6 (15.80), respectively, at week 8. Totally, 59.2% of patients achieved functional remission (SDS≤6) and 61.7% of patients achieved depression remission (MADRS≤10) at week 8; 48.1% of patients achieved both functional and depression remission (SDS≤6 and MADRS≤10). The change in SDS total score was positively correlated with the change in MADRS and HAM-A total scores at each visit. Patient's baseline SDS score was related with depression score (regression coefficient=0.40582, p=0.0005); remission of SDS was statistically related to a reduction of week 2 and week 6 HAM-A score (p<0.0001) and reduction of MADRS score (p<0.0001). Overall, 25.7% of patients reported ≥1 TEAEs. Most frequently reported TEAEs were nausea (5.8%), diarrhea (2.3%), and dizziness (2.7%). Most TEAEs were mild to moderate in severity. Four patients reported serious TEAEs, two patients reported suicide attempts, and one patient completed suicide. CONCLUSION Escitalopram (10-20 mg/day) treatment was efficacious in reducing depression, improving social function, and quality of life in MDD patients with anxiety symptoms. No new safety signals were identified.
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Affiliation(s)
- Gang Wang
- Psychiatry Department, Beijing Anding Hospital, Capital Medical University, National Clinical Research Center for Mental Disorders, Beijing, China
| | - Xiumin You
- Psychiatry Department, Xianyue Hospital, Xiamen, China
| | - Xueyi Wang
- Psychiatry Department, Institute of Mental Health of Hebei Medical University, Shijiazhuang, China
| | - Xiufeng Xu
- Psychiatry Department, Kunming Medical University Affiliated Hospital, Kunming, China
| | - Ludong Bai
- Psychiatry Department, Shangdong Province Mental Hospital, Jinan, China
| | - Jian Xie
- Psychiatry Department, Hangzhou First People Hospital, Hangzhou, China
| | - Zhijian Yao
- Psychiatry Department, Nanjing Brain Hospital, Nanjing, China
| | - QiZhong Yi
- Psychiatry Department, Xinjiang University Affiliated First Hospital, Urumqi, China
| | - Jun Ma
- Psychiatry Department, Inner Mongolia Mental Hospital, Hulun Buir, China
| | - Jinan Wang
- Medical Department, Lundbeck Pharmaceutical Information Consulting Co., Ltd., Beijing, China
| | - Jianmin Zhuo
- Medical Department, Xi'an Janssen Pharmaceutical Ltd., Beijing, China,
| | - Cuili Hu
- Medical Department, Xi'an Janssen Pharmaceutical Ltd., Beijing, China,
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Gender differences in quality of life and functional disability for depression outpatients with or without residual symptoms after acute phase treatment in China. J Affect Disord 2017; 219:141-148. [PMID: 28550766 DOI: 10.1016/j.jad.2017.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/29/2017] [Accepted: 05/04/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Depression is associated with substantial personal suffering and reduced quality of life and functioning. The aim of this study was to investigate gender differences on quality of life and functional impairment of outpatients with depression after acute phase treatment. METHODS 1503 depression outpatients were recruited from eleven hospitals in China. Subjects were evaluated with sociodemographic characteristics, history and self-report instruments, related to severity of symptoms, function and quality of life. All data were analyzed to determine the gender differences. RESULTS Men had a younger age at onset and the first onset age, higher education compared to women in total patients and with or without residual symptoms group. Using regression analysis, it was found that gender was significantly statistically related to severity scores of SDS and had no correlation with Q-LES-Q-SF total scores. In the residual symptoms group, greater functional impairment was noted by men in the area of work and social life. Significant gender differences of mood, work and sexual life in quality of life were observed. LIMITATIONS This is a cross-sectional study of depressed outpatients and duration of acute phase treatment may not an adequate time to measure changes. CONCLUSIONS Depression appears to affect men more seriously than women after acute phase treatment. Men had a younger age at onset and the first onset age, higher education, more functional impairment and lower satisfaction of quality of life in mood, work and sexual life. Gender differences affect acute treatment, remission and recovery.
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Florea I, Loft H, Danchenko N, Rive B, Brignone M, Merikle E, Jacobsen PL, Sheehan DV. The effect of vortioxetine on overall patient functioning in patients with major depressive disorder. Brain Behav 2017; 7:e00622. [PMID: 28293465 PMCID: PMC5346512 DOI: 10.1002/brb3.622] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 10/05/2016] [Accepted: 11/09/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The objectives of this meta-analysis of data from randomized, placebo-controlled studies were to assess the effect of vortioxetine on overall functioning (primary) and functional remission (secondary) using the Sheehan Disability Scale (SDS) in adults with major depressive disorder (MDD). METHODS Data from nine short-term (6/8 weeks) pivotal studies that included patient functioning assessments were included in this random-effects meta-analysis, which used aggregated study-level data for all therapeutic vortioxetine doses and a mixed-effect model for repeated measures using the full analysis set. RESULTS A total of 4,216 patients received ≥1 dose of study treatment (1,522 placebo, 2,694 vortioxetine 5-20 mg/day). At study end, the meta-analysis showed improvement for vortioxetine versus placebo (n = 911) in SDS total score (vortioxetine 5 mg, n = 564, change from baseline versus placebo [Δ] -0.24, p = NS; 10 mg, n = 445, Δ -1.68, p ≤ .001; 15 mg, n = 204, Δ -0.91, p = NS; 20 mg, n = 340, Δ -1.94, p ≤ .01). Functional remission (SDS total score ≤6) was observed with vortioxetine 10 mg (n = 170/573; odds ratio [OR] relative to placebo 1.7, p < .001) and 20 mg (n = 144/447; OR 1.6, p < .05), but not 5 mg (n = 207/757; OR 1.1, p = NS) or 15 mg (n = 92/295; OR 1.3, p = NS). CONCLUSION Vortioxetine 5-20 mg for 6/8 weeks improved overall patient functioning in patients with MDD. Relative to placebo, vortioxetine 10 and 20 mg demonstrated significant improvement in SDS total score and functional remission.
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Affiliation(s)
| | | | | | | | | | | | | | - David V Sheehan
- University of South Florida College of Medicine Tampa FL USA
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Sheehan DV, Mancini M, Wang J, Berggren L, Cao H, Dueñas HJ, Yue L. Assessment of functional outcomes by Sheehan Disability Scale in patients with major depressive disorder treated with duloxetine versus selective serotonin reuptake inhibitors. Hum Psychopharmacol 2016; 31:53-63. [PMID: 26331440 PMCID: PMC5049604 DOI: 10.1002/hup.2500] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 05/11/2015] [Accepted: 07/10/2015] [Indexed: 12/03/2022]
Abstract
OBJECTIVE We compared functional impairment outcomes assessed with Sheehan Disability Scale (SDS) after treatment with duloxetine versus selective serotonin reuptake inhibitors (SSRIs) in patients with major depressive disorder. METHODS Data were pooled from four randomized studies comparing treatment with duloxetine and SSRIs (three double blind and one open label). Analysis of covariance, with last-observation-carried-forward approach for missing data, explored treatment differences between duloxetine and SSRIs on SDS changes during 8 to 12 weeks of acute treatment for the intent-to-treat population. Logistic regression analysis examined the predictive capacity of baseline patient characteristics for remission in functional impairment (SDS total score ≤ 6 and SDS item scores ≤ 2) at endpoint. RESULTS Included were 2193 patients (duloxetine n = 1029; SSRIs n = 835; placebo n = 329). Treatment with duloxetine and SSRIs resulted in significantly (p < 0.01) greater improvements in the SDS total score versus treatment with placebo. Higher SDS (p < 0.0001) or 17-item Hamilton Depression Rating Scale baseline scores (p < 0.01) predicted lower probability of functional improvement after treatment with duloxetine or SSRIs. Female gender (p ≤ 0.05) predicted higher probability of functional improvement after treatment with duloxetine or SSRIs. CONCLUSIONS Treatment with SSRIs and duloxetine improved functional impairment in patients with major depressive disorder. Higher SDS or 17-item Hamilton Depression Rating Scale baseline scores predicted less probability of SDS improvement; female gender predicted better improvement in functional impairment at endpoint.
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Affiliation(s)
- David V Sheehan
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | - Jianing Wang
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
| | | | - Haijun Cao
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
| | | | - Li Yue
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
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