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Aggestrup AS, Martiny F, Lund Henriksen L, Davidsen AS, Martiny K. Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: A scoping review. PLoS One 2024; 19:e0302229. [PMID: 38709769 PMCID: PMC11073719 DOI: 10.1371/journal.pone.0302229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
INTRODUCTION Major Depressive Disorder (MDD) is one of the most prevalent mental disorders worldwide with significant personal and public health consequences. After an episode of MDD, the likelihood of relapse is high. Therefore, there is a need for interventions that prevent relapse of depression when outpatient mental health care treatment has ended. This scoping review aimed to systematically map the evidence and identify knowledge gaps in interventions that aimed to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care. MATERIALS AND METHODS We followed the guidance by Joanna Briggs Institute in tandem with the PRISMA extension for Scoping Reviews checklist. Four electronic databases were systematically searched using controlled index-or thesaurus terms and free text terms, as well as backward and forward citation tracking of included studies. The search strategy was based on the identification of any type of intervention, whether simple, multicomponent, or complex. Three authors independently screened for eligibility and extracted data. RESULTS 18 studies were included for review. The studies had high heterogeneity in design, methods, sample size, recovery rating scales, and type of interventions. All studies used several elements in their interventions; however, the majority used cognitive behavioural therapy conducted in outpatient mental health services. No studies addressed the transitioning phase from outpatient mental health services to primary care. Most studies included patients during their outpatient mental health care treatment of MDD. CONCLUSIONS We identified several knowledge gaps. Recovery interventions for patients with MDD transitioning from outpatient mental health services to primary care are understudied. No studies addressed interventions in this transitioning phase or the patient's experience of the transitioning process. Research is needed to bridge this gap, both regarding interventions for patients transitioning from secondary to primary care, and patients' and health care professionals' experiences of the interventions and of what promotes recovery. REGISTRATION A protocol was prepared in advance and registered in Open Science Framework (https://osf.io/ah3sv), published in the medRxiv server (https://doi.org/10.1101/2022.10.06.22280499) and in PLOS ONE (https://doi.org/10.1371/journal.pone.0291559).
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Affiliation(s)
- Anne Sofie Aggestrup
- The Research Unit for Mental Health Centre Copenhagen, Copenhagen Affective Disorder Research Centre (CADIC), New Interventions in Depression (NID) Group, Mental Health Services in the Capital Region of Denmark, University of Copenhagen, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Frederik Martiny
- The Research Unit for and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Social Medicine, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Line Lund Henriksen
- The Research Unit for Mental Health Centre Copenhagen, Copenhagen Affective Disorder Research Centre (CADIC), New Interventions in Depression (NID) Group, Mental Health Services in the Capital Region of Denmark, University of Copenhagen, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Annette Sofie Davidsen
- The Research Unit for and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Martiny
- The Research Unit for Mental Health Centre Copenhagen, Copenhagen Affective Disorder Research Centre (CADIC), New Interventions in Depression (NID) Group, Mental Health Services in the Capital Region of Denmark, University of Copenhagen, Frederiksberg Hospital, Frederiksberg, Denmark
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Bockting C, Legemaat AM, van der Stappen JGJ, Geurtsen GJ, Semkovska M, Burger H, Bergfeld IO, Lous N, Denys DAJP, Brouwer M. Augmenting neurocognitive remediation therapy to Preventive Cognitive Therapy for partially remitted depressed patients: protocol of a pragmatic multicentre randomised controlled trial. BMJ Open 2022; 12:e063407. [PMID: 35738653 PMCID: PMC9226921 DOI: 10.1136/bmjopen-2022-063407] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Major depressive disorder (MDD) affects 163 million people globally every year. Individuals who experience subsyndromal depressive symptoms during remission (ie, partial remission of MDD) are especially at risk for a return to a depressive episode within an average of 4 months. Simultaneously, partial remission of MDD is associated with work and (psycho)social impairment and a lower quality of life. Brief psychological interventions such as preventive cognitive therapy (PCT) can reduce depressive symptoms or relapse for patients in partial remission, although achieving full remission with treatment is still a clinical challenge. Treatment might be more effective if cognitive functioning of patients is targeted as well since cognitive problems are the most persisting symptom in partial remission and predict poor treatment response and worse functioning. Studies show that cognitive functioning of patients with (remitted) MDD can be improved by online neurocognitive remediation therapy (oNCRT). Augmenting oNCRT to PCT might improve treatment effects for these patients by strengthening their cognitive functioning alongside a psychological intervention. METHODS AND ANALYSIS This study will examine the effectiveness of augmenting oNCRT to PCT in a pragmatic national multicentre superiority randomised controlled trial. We will include 115 adults partially remitted from MDD with subsyndromal depressive symptoms defined as a Hamilton Depression Rating Scale score between 8 and 15. Participants will be randomly allocated to PCT with oNCRT, or PCT only. Primary outcome measure is the effect on depressive symptomatology over 1 year. Secondary outcomes include time to relapse, cognitive functioning, quality of life and healthcare costs. This first dual approach study of augmenting oNCRT to PCT might facilitate full remission in partially remitted individuals as well as prevent relapse over time. ETHICS AND DISSEMINATION Ethical approval was obtained by Academic Medical Center, Amsterdam. Outcomes will be made publicly available. TRIAL REGISTRATION NUMBER NL9582.
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Affiliation(s)
- Claudi Bockting
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Centre for Urban Mental Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Amanda M Legemaat
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Gert J Geurtsen
- Department of Medical Psychology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Maria Semkovska
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Huibert Burger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Isidoor O Bergfeld
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Damiaan A J P Denys
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Marlies Brouwer
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
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Blomdahl C, Guregård S, Rusner M, Wijk H. Recovery From Depression—A 6-Month Follow-up of a Randomized Controlled Study of Manual-Based Phenomenological Art Therapy for Persons With Depression. ART THERAPY 2021. [DOI: 10.1080/07421656.2021.1922328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sánchez J. Predicting Recovery in Individuals With Serious Mental Illness: Expanding the International Classification of Functioning, Disability, and Health (ICF) Framework. REHABILITATION COUNSELING BULLETIN 2020. [DOI: 10.1177/0034355220976835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
People with psychiatric disabilities experience significant impairment in fulfilling major life roles due to the severity of their mental illness. Recovery for people with serious mental illness (SMI) can be a long, arduous process, impacted by various biological, functional, sociological, and psychological factors which can present as barriers and/or facilitators. The purposes of this study were to: (a) investigate the International Classification of Functioning, Disability, and Health (ICF) framework’s ability to predict recovery in adults with SMI and (b) determine to what extent the ICF constructs in the empirical model explain the variance in recovery. Participants ( N = 192) completed a sociodemographic questionnaire and various measures representing all predictor and outcome variables. Results from hierarchical regression analysis with six sets of predictors entered sequentially (1 = personal factors-demographics, 2 = body functions-mental, 3 = activity-capacity, 4 = environmental factors, 5 = personal factors-characteristics, and 6 = participation-performance) accounted for 75% (large effect) of the variance in recovery. Controlling for all factors, by order of salience, higher levels of significant other support, education, executive function impairment, and social self-efficacy; primary, non-bipolar SMI diagnosis; greater resilience; lower levels of explicit memory-health impairment, affective self-stigma, and cognitive self-stigma; being younger; fewer self-care limitations; less severe psychiatric symptoms; and being unemployed and unmarried were found to significantly predict recovery. Findings support the validation of the ICF framework as a biopsychosocial recovery model and the use of this model in the development of effective recovery-oriented interventions for adults with SMI. Clinical and research implications are discussed.
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Boulenger JP. Residual symptoms of depression: clinical and theoretical implications. Eur Psychiatry 2020; 19:209-13. [PMID: 15196602 DOI: 10.1016/j.eurpsy.2004.04.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2003] [Accepted: 01/01/2004] [Indexed: 11/30/2022] Open
Abstract
AbstractResidual symptoms of variable intensity often persist following pharmaco/or psychotherapeutic interventions for treatment of major depression (MD). In several studies, such persistent symptoms have been clearly shown to be associated with a higher risk of relapse, chronicity and functional impairment, but their true nature is still controversial. Several authors consider that these symptoms belong to the range of depression proper and thus indicate that the current episode has been inadequately treated, a hypothesis reinforced by their frequent similarity with the symptoms preceding the full-blown picture of MD. However, in the current state of research, their connection with certain personality traits or comorbid disorders—notably anxiety disorders—cannot be completely ruled out. This article reviews the main data from the literature concerning residual symptoms and their treatment, as well as the issues related to their psychopathological meaning. In practice, once the state of a patient has been stabilized in partial remission of the depressive syndrome, the clinician should revise the current therapeutic strategy and seek to find how to return as fully as possible to the previous euthymic state.
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Affiliation(s)
- Jean-Philippe Boulenger
- University Department of Adult Psychiatry, CHU de Montpellier, 34295 Montpellier cedex 5, France.
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Eidelman P, Jensen A, Rappaport LM. Social support, negative social exchange, and response to case formulation-based cognitive behavior therapy. Cogn Behav Ther 2018; 48:146-161. [PMID: 30015573 DOI: 10.1080/16506073.2018.1490809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We investigated associations between pretreatment social support, negative social exchange, and slope of weekly symptom change for depression, anxiety, and stress over the course of ideographic, case formulation-based, cognitive behavior therapy. Participants were 74 adults treated in a private practice setting. We used self-report measures to assess social support and negative social exchange at intake and to assess symptoms on a weekly basis. At pretreatment, a higher level of social support was associated with lower levels of depression, and a higher level of negative social exchanges was associated with higher levels of depression and stress. Pretreatment social support was not significantly associated with slope of symptom change. However, a higher level of pretreatment negative social exchanges was associated with steeper slope of change in symptoms of depression and stress during treatment. These findings suggest that the association between pretreatment negative social exchanges and subsequent symptoms may be stronger than that of social support and subsequent symptoms. Additionally, we discuss the possibility that having data on negative social exchanges at the start of treatment may benefit the outcome of ideographic, case formulation-based, cognitive behavior therapy.
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Affiliation(s)
- Polina Eidelman
- a Redwood Center for Cognitive Behavior Therapy and Research , Oakland , CA , USA
| | - Alexandra Jensen
- a Redwood Center for Cognitive Behavior Therapy and Research , Oakland , CA , USA
| | - Lance M Rappaport
- b Virginia Commonwealth University, Virginia Institute for Psychiatric and Behavioral Genetics , Richmond , VA , USA
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Bayliss AP, Tipper SP, Wakeley J, Cowen PJ, Rogers RD. Vulnerability to depression is associated with a failure to acquire implicit social appraisals. Cogn Emot 2016; 31:825-833. [PMID: 27050201 PMCID: PMC5415677 DOI: 10.1080/02699931.2016.1160869] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Major depressive disorder (MDD) is associated with disrupted relationships with partners, family, and peers. These problems can precipitate the onset of clinical illness, influence severity and the prospects for recovery. Here, we investigated whether individuals who have recovered from depression use interpersonal signals to form favourable appraisals of others as social partners. Twenty recovered-depressed adults (with >1 adult episode of MDD but euthymic and medication-free for six months) and 23 healthy, never-depressed adults completed a task in which the gaze direction of some faces reliably cued the location a target (valid faces), whereas other faces cued the opposite location (invalid faces). No participants reported awareness of this contingency, and both groups were significantly faster to categorise targets following valid compared with invalid gaze cueing faces. Following this task, participants judged the trustworthiness of the faces. Whereas the healthy never-depressed participants judged the valid faces to be significantly more trustworthy than the invalid faces; this implicit social appraisal was absent in the recovered-depressed participants. Individuals who have recovered from MDD are able to respond appropriately to joint attention with other people but appear to not use joint attention to form implicit trust appraisals of others as potential social partners.
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Affiliation(s)
- Andrew P Bayliss
- a School of Psychology , University of East Anglia , Norwich , UK
| | | | - Judi Wakeley
- c Department of Psychiatry , University of Oxford , Oxford , UK
| | - Phillip J Cowen
- c Department of Psychiatry , University of Oxford , Oxford , UK
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IsHak WW, James DM, Mirocha J, Youssef H, Tobia G, Pi S, Collison KL, Cohen RM. Patient-reported functioning in major depressive disorder. Ther Adv Chronic Dis 2016; 7:160-9. [PMID: 27347363 DOI: 10.1177/2040622316639769] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Compared with the general population, patients with major depressive disorder (MDD) report substantial deficits in their functioning that often go beyond the clinical resolution of depressive symptoms. This study examines the impact of MDD and its treatment on functioning. METHODS From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, we analyzed complete data of 2280 adult outpatients with MDD at entry and exit points of each level of antidepressant treatment and again 12 months post treatment. Functioning was measured using the Work and Social Adjustment Scale (WSAS). RESULTS The results show that only 7% of patients with MDD reported within-normal functioning before treatment. The proportion of patients achieving within-normal functioning (WSAS) scores significantly increased after treatment. However, the majority of patients (>60%) were still in the abnormal range on functioning at exit. Although remitted patients had greater improvements compared with nonremitters, a moderate proportion of remitted patients continued to experience ongoing deficits in functioning after treatment (20-40%). Follow-up data show that the proportions of patients experiencing normal scores for functioning after 12 months significantly decreased from the end of treatment to the follow-up phase, from 60.1% to 49% (p < 0.0001), a finding that was particularly significant in nonremitters. Limitations of this study include the reliance on self-report of functioning and the lack of information on patients who dropped out. CONCLUSION This study points to the importance of functional outcomes of MDD treatment as well as the need to develop personalized interventions to improve functioning in MDD.
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Affiliation(s)
- Waguih William IsHak
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians E-132, Los Angeles, CA 90048, USA
| | - David M James
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James Mirocha
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Haidy Youssef
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gabriel Tobia
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sarah Pi
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Katherine L Collison
- Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert M Cohen
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
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Camardese G, Mazza M, Zaninotto L, Leone B, Marano G, Serrani R, Di Nicola M, Bria P, Janiri L. Clinical correlates of difficult-to-treat depression: Exploring an integrated day-care model of treatment. Nord J Psychiatry 2016; 70:45-52. [PMID: 26065468 DOI: 10.3109/08039488.2015.1048719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND AIMS This study aimed to test the effectiveness of an individualized, integrated, day-care treatment programme for the acute phase of "difficult-to-treat depression" (DTD) in a sample of bipolar and unipolar subjects with a complex co-morbidity pattern. METHODS A total of 291 patients meeting criteria for DTD were consecutively recruited. All participants underwent a 12-week day-care intervention including individual psychological support and group psycho-education. Subjects were assessed for depressive symptom severity by the 21-item Hamilton Depression Rating Scale (HDRS) at the baseline (T0) and after 4 (T1) and 12 (T2) weeks of treatment. A repeated measures general linear model was performed to test for interactive effects among variables. RESULTS An overall significant improvement was detected in the majority of cases (F = 138.6, p < 0.0001). Responders reported lower rates of personality disorders and higher baseline depressive severity. An interaction between bipolarity and co-morbidity was associated with a poorer outcome (F = 5.9, p = 0.0034). Family involvement was the only significant predictor for symptom improvement (F = 7.9, adjusted p = 0.0025). CONCLUSIONS Our intervention proved to be effective in the treatment of complex and severe forms of depression. Our results on the role of family support require further investigation to better define suitable targets for tailored therapeutic approaches.
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Affiliation(s)
- Giovanni Camardese
- a Giovanni Camardese, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , Italy
| | - Marianna Mazza
- b Marianna Mazza, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , Italy
| | - Leonardo Zaninotto
- c Leonardo Zaninotto, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , and Department of Biomedical and Neuro-Motor Sciences , University of Bologna , Bologna , Italy
| | - Beniamino Leone
- d Beniamino Leone, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , Italy
| | - Giuseppe Marano
- e Giuseppe Marano, Institute of Neurology, Catholic University of the Sacred Heart , Rome , Italy
| | - Riccardo Serrani
- f Riccardo Serrani, Institute of Neurology, Catholic University of the Sacred Heart , Rome , Italy
| | - Marco Di Nicola
- g Marco Di Nicola, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , Italy
| | - Pietro Bria
- h Pietro Bria, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , Italy
| | - Luigi Janiri
- i Luigi Janiri, Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart , Rome , Italy
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Rate and Predictors of Persistent Major Depressive Disorder in a Nationally Representative Sample. Community Ment Health J 2015; 51:701-7. [PMID: 25527224 PMCID: PMC4475503 DOI: 10.1007/s10597-014-9793-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 12/06/2014] [Indexed: 10/24/2022]
Abstract
This study examined predictors of persistent major depressive disorder over 10 years, focusing on the effects of clinical variables, physical health, and social support. Data from the National Survey of Midlife Development in the United States in 1995-1996 and 2004-2006 were analyzed. Logistic regression was used to predict non-recovery from major depression among individuals who met clinical-based criteria for major depressive disorder at baseline. Fifteen percent of the total sample was classified as having major depression in 1995-1996; of these individuals, 37 % had major depression in 2004-2006. Baseline variables that were significantly associated with persistent major depression at follow-up were being female, having never married, having two or more chronic medical conditions, experiencing activity limitation, and less contact with family. Therefore, treatment strategies focused on physical health, social support, and mental health needs are necessary to comprehensively address the factors that contribute to persistent major depressive disorder.
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Cleare A, Pariante CM, Young AH, Anderson IM, Christmas D, Cowen PJ, Dickens C, Ferrier IN, Geddes J, Gilbody S, Haddad PM, Katona C, Lewis G, Malizia A, McAllister-Williams RH, Ramchandani P, Scott J, Taylor D, Uher R. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015; 29:459-525. [PMID: 25969470 DOI: 10.1177/0269881115581093] [Citation(s) in RCA: 399] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.
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Affiliation(s)
- Anthony Cleare
- Professor of Psychopharmacology & Affective Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - C M Pariante
- Professor of Biological Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - A H Young
- Professor of Psychiatry and Chair of Mood Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - I M Anderson
- Professor and Honorary Consultant Psychiatrist, University of Manchester Department of Psychiatry, University of Manchester, Manchester, UK
| | - D Christmas
- Consultant Psychiatrist, Advanced Interventions Service, Ninewells Hospital & Medical School, Dundee, UK
| | - P J Cowen
- Professor of Psychopharmacology, Psychopharmacology Research Unit, Neurosciences Building, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - C Dickens
- Professor of Psychological Medicine, University of Exeter Medical School and Devon Partnership Trust, Exeter, UK
| | - I N Ferrier
- Professor of Psychiatry, Honorary Consultant Psychiatrist, School of Neurology, Neurobiology & Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J Geddes
- Head, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - S Gilbody
- Director of the Mental Health and Addictions Research Group (MHARG), The Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - P M Haddad
- Consultant Psychiatrist, Cromwell House, Greater Manchester West Mental Health NHS Foundation Trust, Salford, UK
| | - C Katona
- Division of Psychiatry, University College London, London, UK
| | - G Lewis
- Division of Psychiatry, University College London, London, UK
| | - A Malizia
- Consultant in Neuropsychopharmacology and Neuromodulation, North Bristol NHS Trust, Rosa Burden Centre, Southmead Hospital, Bristol, UK
| | - R H McAllister-Williams
- Reader in Clinical Psychopharmacology, Institute of Neuroscience, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - P Ramchandani
- Reader in Child and Adolescent Psychiatry, Centre for Mental Health, Imperial College London, London, UK
| | - J Scott
- Professor of Psychological Medicine, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - D Taylor
- Professor of Psychopharmacology, King's College London, London, UK
| | - R Uher
- Associate Professor, Canada Research Chair in Early Interventions, Dalhousie University, Department of Psychiatry, Halifax, NS, Canada
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Unger T, Hoffmann S, Köhler S, Mackert A, Fydrich T. Personality disorders and outcome of inpatient treatment for depression: a 1-year prospective follow-up study. J Pers Disord 2013; 27:636-51. [PMID: 22928855 DOI: 10.1521/pedi_2012_26_052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study examines the relationship of personality disorders (PDs) with the outcome of an inpatient treatment for depression. One hundred sixty-eight inpatients with unipolar depression (41% with PD according to SCID-II) were assessed at admission, discharge, and 1-year follow-up. Patients without as well as with PD showed a significant and comparable intake-to-discharge symptom reduction in all inventories. At posttreatment, patients with PD scored higher in self-report measures of symptom severity (Brief Symptom Inventory, Beck Depression Inventory) than patients without PD, due to their higher symptom levels at intake. However, there was no difference in clinician-rated therapy outcome (Hamilton Rating Scale for Depression [17-item version], Global Assessment of Functioning Scale, Clinical Global Impression Scale) between both patient groups at discharge. At 1-year follow-up, patients without PD maintained their treatment outcome, whereas patients with PD showed a slight increase in symptom severity, compared to discharge. The results suggest that a difference in acute treatment outcome between depressed patients with and without PD may be found using self-ratings but not expert ratings of symptom severity. Furthermore, the importance of subsequent outpatient treatment that takes into account the special needs of depressed patients with comorbid PD is highlighted.
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Social support resources and post-acute recovery for older adults with major depression. Community Ment Health J 2013; 49:419-26. [PMID: 23229054 DOI: 10.1007/s10597-012-9567-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 11/02/2012] [Indexed: 10/27/2022]
Abstract
This study assessed the relationships between older patients' social support resources and depressive symptoms and psychosocial functioning at 6 months following a psychiatric hospital discharge. The data used in this study were extracted from a prospective study titled "Service Use of Depressed Elders after Acute Care" (National Institute of Mental Health-56208). This sample included 148 older patients who participated in the initial and the 6-month follow-up assessment. Ordinary Least Squares regression (OLS) was used to examine important social support resources in relation to older patients' depressive symptoms and psychosocial functioning. A vast majority of patients were embedded in a social support network that consisted of acquaintances and confidants. Patients' depressive symptoms were related to availability of a confidant and the extent to which they spent time with others. However, patients' psychosocial functioning was not related to social support resources assessed in this study.
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Rundell JR. Factors Associated with Depression Treatment-Response in an Outpatient Psychosomatic Medicine Practice: An Exploratory Retrospective Study. PSYCHOSOMATICS 2012; 53:387-91. [DOI: 10.1016/j.psym.2011.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 04/18/2011] [Accepted: 04/21/2011] [Indexed: 11/25/2022]
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Abstract
Given the limitations of evidence for treatment options that are consistently effective for TRD and the possibility that TRD is in fact a form of depression that has a low probability of resolving, how can clinicians help patients with TRD? Perhaps the most important conceptual shift that needs to take place before treatment can be helpful is to accept TRD as a chronic illness, an illness similar to many others, one that can be effectively managed but that is not, at our present level of knowledge, likely to be cured. An undue focus on remission or even a 50% diminution of symptoms sets unrealistic goals for both patients and therapists and may lead to overtreatment and demoralization. The focus should be less on eliminating depressive symptoms and more on making sense of and learning to function better in spite of them. It is important to acknowledge the difficult nature of the depressive illness, to remove blame from the patient and clinician for not achieving remission, to set realistic expectations, and to help promote better psychosocial functioning even in the face of persisting symptoms. The critical element when implementing such an approach is a judicious balance between maintaining hope for improvement without setting unrealistic expectations. It is important to reemphasize that following a disease management model with acceptance of the reality of a chronic illness is not nihilistic and does not mean the abandonment of hope for improvement. The first step in treating a patient with TRD is to perform a comprehensive assessment of the patient’s past and current treatment history to ensure that evidence-based treatment trials have in fact been undertaken, and if not, such treatment trials should be implemented. If the patient continues to have significant residual symptoms, it is important to determine the impact is of these symptoms on the patient’s quality of life and ability to function. It is also important to evaluate the factors that may be contributing to the persistence of depressive symptoms such as comorbid personality disorders, somatic disorders, substance abuse, and work and interpersonal conflicts. The treatment of patients with TRD needs to move beyond attempts to modify symptoms without taking into consideration and attempting to modify the patient’s personality, coping skills, and social system. Further somatic treatment trials can be undertaken, if desired by the patient and therapist, as a small (5%–15%) percentage of patients may respond and further treatment trials, and this may engender hope. The risk with this approach is that patients and therapists may not work at disease management skills if they believe there may be a resolution of the depression if they could just find the right medication or intervention. Therapists may also feel pressured by patients, families, insurance companies, as well as their own sense of helplessness to escalate treatment in a more and more aggressive manner in an attempt to achieve an elusive remission. A disease management program can provide the therapist and patient with sufficient structure, skills, and goals to encourage ongoing treatment without resorting to unproven measures that may create more side effects and problems. It is particularly important to include the patient’s significant others in the reformulation of the patient’s problem and thereby learn how to manage the illness more effectively. Significant others and family members can be invaluable in providing support for dealing with the difficult process of acquiring a new skill set. Indeed, they spend significantly more time with the patient than does any therapist. Family members are likely to provide this kind of support only if they have been part of the assessment and treatment process. Patients with a wide range of chronic medical illnesses can and do learn to function effectively and to achieve a satisfying quality of life in spite of their illness. There is no reason to think that patients with TRD should not be able to achieve a similar level of illness management, functioning, and quality of life.
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Affiliation(s)
- Gabor I Keitner
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912, USA.
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Antidepressant augmentation and combination in unipolar depression: strong guidance, weak foundations. Ir J Psychol Med 2011; 28:i-ix. [PMID: 30200016 DOI: 10.1017/s0790966700011800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Depression will be the second leading contributor to the global burden of disease by 2020. In Ireland, in 2009, 6061 people were hospitalised with depressive disorders. This represents a significant economic and social burden. There is growing awareness of the difficulty in treating depression with medications alone. The likelihood that a patient will achieve remission with the first antidepressant tried is around 30%, and the rates are similar for the second antidepressant tried. This falls to around 15% after three trials. Many patients are exposed to pharmacotherapy for extended periods of time with little beneficial effect, but often with side-effects. Patients are therefore in great need of clear information with regard to their chance of success. Clinicians are in need of clear guidance on prescribing strategies which have proven efficacy. However, this guidance often discusses treatment strategies based on varying levels of evidence. Guiding bodies may approach the problem from varying perspectives. The UK National Institute for Health and Clinical Excellence (NICE) has a clear government mandate with regard to provision of not only effective but cost-effective treatments. The British Association of Psychopharmacology (BAP) is an independent body of interested researchers and therefore may discuss prescribing options from the point of view of tertiary care institutions, and university centres. The South London and Maudsley NHS Foundation Trust publish the popular Maudsley guidelines. These are perhaps more pragmatic in nature, but include very low levels of evidence, including case series. The American Psychiatric Association (APA) is an independent member association which also publishes guidelines. These are published in the American Journal of Psychiatry and the latest guidelines were published in October 2010. All these bodies attempt to weigh their advice according to the level of evidence available and aim to provide clinical guidance in difficult situations. The burden on guiding organisations is to provide some direction and clarity in areas that are often unclear or controversial. Clinical guidelines are one method of providing support and guidance to busy clinicians. However, this clinician-centered approach has limitations. The onus is on the authors of the guidance to provide ever-more treatment options. This may mean that conclusions about the efficacy of medications is overstated or the limitations of the literature not fully explored in explanatory notes.
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Gadelrab HF, Cabello M, Vieta E, Valle J, Leonardi M, Chatterji S, Ayuso-Mateos JL. Explaining functional outcomes in depression treatment: a multilevel modelling approach. Disabil Rehabil 2010; 32 Suppl 1:S105-15. [DOI: 10.3109/09638288.2010.520808] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Talbot F, Harris GE, French DJ. Treatment outcome in psychiatric inpatients: the discriminative value of self-esteem. Int J Psychiatry Med 2010; 39:227-41. [PMID: 19967897 DOI: 10.2190/pm.39.3.b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
UNLABELLED Self-esteem has been identified as an important clinical variable within various psychological and psychiatric conditions. Surprisingly, its prognostic and discriminative value in predicting treatment outcome has been understudied. OBJECTIVE The current study aims to assess, in an acute psychiatric setting, the comparative role of self-esteem in predicting treatment outcome in depression, anxiety, and global symptom severity, while controlling for socio-demographic variables, pre-treatment symptom severity, and personality pathology. DESIGN Treatment outcome was assessed with pre- and post-treatment measures. METHOD A heterogeneous convenience sample of 63 psychiatric inpatients completed upon admission and discharge self-report measures of depression, anxiety, global symptom severity, and self-esteem. RESULTS A significant one-way repeated-measures multivariate analysis of variance (MANOVA) followed up by analyses of variance (ANOVAs) revealed significant reductions in depression (eta2 = .72), anxiety (eta2 = .55), and overall psychological distress (eta2 = .60). Multiple regression analyses suggested that self-esteem was a significant predictor of short-term outcome in depression but not for anxiety or overall severity of psychiatric symptoms. The regression model predicting depression outcome explained 32% of the variance with only pre-treatment self-esteem contributing significantly to the prediction. CONCLUSIONS The current study lends support to the importance of self-esteem as a pre-treatment patient variable predictive of psychiatric inpatient treatment outcome in relation with depressive symptomatology. Generalization to patient groups with specific diagnoses is limited due to the heterogeneous nature of the population sampled and the treatments provided. Implications for clinical practice and future research are discussed.
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Affiliation(s)
- France Talbot
- Ecole de Psychologie, Université de Moncton, Canada.
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McKenzie M, Clarke DM, McKenzie DP, Smith GC. Which factors predict the persistence of DSM-IV depression, anxiety, and somatoform disorders in the medically ill three months post hospital discharge? J Psychosom Res 2010; 68:21-8. [PMID: 20004297 DOI: 10.1016/j.jpsychores.2009.08.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 08/10/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study sought to assess the persistence of DSM-IV depression, anxiety, and somatoform disorders in a sample of 206 medical patients 3 months after hospital discharge and to examine which baseline factors predicted the persistence of disorder. METHODS Patients were interviewed using the Monash Interview for Liaison Psychiatry (a structured psychiatric interview for the medically ill) during admission and again at 3 months post discharge. Scales completed during admission elicited sociodemographic data, psychiatric history, mental and physical functioning, illness behavior, coping modes, and number of close relationships. Best-subset logistic regression was employed to find the best combination of these potential predictors of the persistence of psychiatric disorder. RESULTS Persistence of anxiety disorders [n=43; 50.6%; 95% CI=39.5-61.6], depression (n=55; 44.4%; 95% CI=35.4-53.5), and somatoform disorders (n=35; 42.2%; 95% CI=31.3-53.0) was moderately high, with no statistically significant difference in the rate of persistence of the three groups of disorder. Family psychiatric history, education, and poorer physical and mental functioning during hospitalization predicted persistence of depression. Poorer mental functioning, less denial, and greater number of close relationships predicted persistence of anxiety disorders. Higher levels of education, use of acceptance-resignation as a coping mechanism, and greater hypochondriasis predicted persistence of somatoform disorders. CONCLUSION The belief that psychiatric disorders in hospitalized medically ill patients spontaneously remit after discharge is false. A substantial proportion persist for at least 3 months. Early detection and treatment is possible and warranted. Features of the illness (poorer physical and mental health) and personal and social factors identifiable at hospital admission identify patients at risk for persistence.
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Affiliation(s)
- Maria McKenzie
- Psychological and Behavioural Medicine Unit, Monash University School of Psychiatry, Psychology, and Psychological Medicine, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia.
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Beckner V, Howard I, Vella L, Mohr DC. Telephone-administered psychotherapy for depression in MS patients: moderating role of social support. J Behav Med 2009; 33:47-59. [PMID: 19941048 PMCID: PMC2813530 DOI: 10.1007/s10865-009-9235-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 11/01/2009] [Indexed: 11/11/2022]
Abstract
Depression is common in individuals with multiple sclerosis (MS). While psychotherapy is an effective treatment for depression, not all individuals benefit. We examined whether baseline social support might differentially affect treatment outcome in 127 participants with MS and depression randomized to either Telephone-administered Cognitive-Behavioral Therapy (T-CBT) or Telephone-administered Emotion-Focused Therapy (T-EFT). We predicted that those with low social support would improve more in T-EFT, since this approach emphasizes the therapeutic relationship, while participants with strong social networks and presumably more emotional resources might fare better in the more structured and demanding T-CBT. We found that both level of received support and satisfaction with that support at baseline did moderate treatment outcome. Individuals with high social support showed a greater reduction in depressive symptoms in the T-CBT as predicted, but participants with low social support showed a similar reduction in both treatments. This suggests that for participants with high social support, CBT may be a more beneficial treatment for depression compared with EFT.
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Affiliation(s)
- Victoria Beckner
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA.
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Fleck MP, Berlim MT, Lafer B, Sougey EB, Del Porto JA, Brasil MA, Juruena MF, Hetem LA. [Review of the guidelines of the Brazilian Medical Association for the treatment of depression (Complete version)]. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2009; 31 Suppl 1:S7-17. [PMID: 19565151 DOI: 10.1590/s1516-44462009000500003] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Depression is a frequent, recurrent and chronic condition with high levels of functional disability. The Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present a review of the Guidelines Published in 2003 incorporating new evidence and recommendations. METHOD This review was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. The Brazilian Medical Association proposed this methodology for the whole project. The review was developed from new international guidelines published since 2003. RESULTS The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Strategies for different phases of treatment are also discussed. CONCLUSION The Guidelines are an important tool for clinical decisions and a reference for orientation based on the available evidence in the literature.
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Affiliation(s)
- Marcelo P Fleck
- Departamento de Psiquiatria e Medicina Legal, Universidade Federal do Rio Grande do Sul, and Programa de Transtornos de Humor, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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Eighteen months of drug treatment for depression: predicting relapse and recovery. J Affect Disord 2009; 114:263-70. [PMID: 18805590 DOI: 10.1016/j.jad.2008.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 08/01/2008] [Accepted: 08/01/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND The clinically relevant outcomes in treating depression are persistent recovery, relapse, and treatment resistance. METHOD 175 outpatients treated with antidepressants for 6 months were assessed for major depression. Those who had recovered were prospectively monitored for one year to study rates of relapse (at least two weeks of major depression). Those who were depressed at 6 months were monitored for rates of recovery (at least 8 weeks of no major depression). RESULTS 94% of the sample was monitored for one year. Of the 123 patients who were not depressed at 6 months 57 (46%) relapsed. Patients who relapsed were more likely to have a history of recurrent depression, to have residual depressive symptoms, to have a less sustained response to initial treatment, to have avoidant personality disorder symptoms, schizotypal personality disorder symptoms, higher harm avoidance (HA) scores and lower self directedness (SD) scores. Of the 38 patients who were depressed at 6 months 13 (34%) recovered. There were no patient characteristics associated with recovery. LIMITATIONS The findings apply to moderately depressed outpatients. There was no placebo control. CONCLUSION Most patients with depression will recover but many become unwell again within a year. Clinically long term monitoring and sustained efforts to treat patients with major depression seem warranted.
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Common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. Int Clin Psychopharmacol 2009; 24:1-18. [PMID: 19060722 DOI: 10.1097/yic.0b013e32831db2d7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study is to summarize available knowledge about common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. A literature search was carried out by using MEDLINE and references of selected articles. The search included articles published up to March 2008. The main genetic finding concerns the serotonin transporter gene promoter polymorphisms, the long variant of which seems to be related to a positive response to therapy in mood disorders and could also have a role in the treatment of anxiety disorders. Among other predictors, the main factors common to both classes of disorder are comorbid axis II disorders and early onset of illness, which are related to a worse response to therapy and concomitant good physical conditions, absence of earlier treatments, early administration and response to therapies, and higher self- directedness, which is related to a better outcome. Many common predictors have been identified and these seem to be related to features covering the totality of patients that go beyond specific characteristics of single disorders. Possible limitations and suggestions for future research based on a more integrated vision of human complexity are discussed.
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Prince JD, Akincigil A, Hoover DR, Walkup JT, Bilder S, Crystal S. Substance abuse and hospitalization for mood disorder among Medicaid beneficiaries. Am J Public Health 2008; 99:160-7. [PMID: 19008505 DOI: 10.2105/ajph.2007.133249] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We compared the influence of substance abuse with that of other comorbidities (e.g., anxiety, HIV) among people with mood disorder (N=129,524) to explore risk factors for psychiatric hospitalization and early readmission within 3 months of discharge. METHODS After linking Medicaid claims data in 5 states (California, Florida, New Jersey, New York, and Texas) to community-level information, we used logistic and Cox regression to examine hospitalization risk factors. RESULTS Twenty-four percent of beneficiaries with mood disorder were hospitalized. Of these, 24% were rehospitalized after discharge. Those with comorbid substance abuse accounted for 36% of all baseline hospitalizations and half of all readmissions. CONCLUSIONS Results highlight the need for increased and sustained funding for the treatment of comorbid substance abuse and mood disorder, and for enhanced partnership between mental health and substance abuse professionals.
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Affiliation(s)
- Jonathan D Prince
- Institute for Health, Health Care Policy, and Aging Research, School of Social Work, Rutgers University, 536 George St, New Brunswick, NJ 08901, USA.
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Abstract
The aim of the present study was to critically appraise current conceptual approaches; demographic, neurobiological and clinical correlates; and management strategies of treatment-resistant depression (TRD), especially in light of recent research findings. To this end, a review of the relevant English-language literature was undertaken using Medline, Embase and Psychinfo. TRD has been defined in conceptually restrictive terms as symptomatic non-response to physical therapies alone, with little systematic study of aetiology made. It is likely that a range of sociodemographic (such as higher socioeconomic status), genetic (such as variation in functional monoamine polymorphisms) and clinical variables (such as signal hyperintensities seen on structural neuroimaging scans) are responsible for non-response in individuals. There is insufficient evidence to suggest that TRD is associated with specific subtypes of depression, physical comorbidity, personality or chronicity. The large-scale Sequenced Treatment Alternatives to Relieve Depression (STAR*D) and other studies have suggested that a structured psychotherapy such as cognitive behaviour therapy may be as effective as medication in initial drug non-responders. Also conventional alternatives such as the use of older antidepressant classes, pharmacological augmentation or electroconvulsive therapy in established cases of TRD are not as effective as traditionally thought. There is insufficient preliminary evidence to make formal recommendations about the use of novel brain stimulation techniques in TRD. TRD should be re-defined as the failure to reach symptomatic and functional remission after adequate treatment with physical and psychological therapies. Treatment resistance may be more usefully conceived within the context of well-defined cohorts such as patients with specific subtypes of depression. Although neurobiological markers such as gene polymorphisms, which are potentially predictive of medication tolerance and efficacy, may be used in the future, it is likely that sociocultural variables such as beliefs about depression, and evidence-based treatments for it, will also determine treatment resistance.
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Affiliation(s)
- Chanaka Wijeratne
- School of Psychiatry, University of New South Wales, Kensington, New South Wales, Australia.
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Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, Matthews K, McAllister-Williams RH, Peveler RC, Scott J, Tylee A. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. J Psychopharmacol 2008; 22:343-96. [PMID: 18413657 DOI: 10.1177/0269881107088441] [Citation(s) in RCA: 335] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.
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Affiliation(s)
- I M Anderson
- Senior Lecturer and Honorary Consultant Psychiatrist, Neuroscience and Psychiatry Unit, University of Manchester, UK.
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Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. J Gen Intern Med 2008; 23:551-60. [PMID: 18247097 PMCID: PMC2324144 DOI: 10.1007/s11606-008-0522-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 12/20/2007] [Accepted: 01/08/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whether the acute outcomes of major depressive disorder (MDD) treated in primary (PC) or specialty care (SC) settings are different is unknown. OBJECTIVE To compare the treatment and outcomes for depressed outpatients treated in primary versus specialty settings with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a broadly inclusive effectiveness trial. DESIGN Open clinical trial with citalopram for up to 14 weeks at 18 primary and 23 specialty sites. Participants received measurement-based care with 5 recommended treatment visits, manualized pharmacotherapy, ongoing support and guidance by a clinical research coordinator, the use of structured evaluation of depressive symptoms and side effects at each visit, and a centralized treatment monitoring and feedback system. PARTICIPANTS A total of 2,876 previously established outpatients in primary (n = 1091) or specialty (n = 1785) with nonpsychotic depression who had at least 1 post-baseline measure. MEASUREMENTS AND MAIN RESULTS Remission (Hamilton Depression Rating Scale for Depression [Hamilton] or 16-item Quick Inventory of Depressive Symptomatology-Self-Rated [QIDS-SR(16)]); response (QIDS-SR(16)); time to first remission (QIDS-SR(16)). Remission rates by Hamilton (26.6% PC vs 28.0% SC, p = .40) and by QIDS-SR(16) (32.5% PC vs 33.1% SC, p = .78) and response rates by QIDS-SR(16) (45.7% PC vs 47.6% SC, p = .33) were not different. For those who reached remission or response at exit, the time to remission (6.2 weeks PC vs 6.9 weeks SC, p = .12) and to response (5.5 weeks PC vs 5.4 weeks SC, p = .97) did not differ by setting. CONCLUSIONS Identical remission and response rates can be achieved in primary and specialty settings when identical care is provided.
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Depressive Störungen. PSYCHIATRIE UND PSYCHOTHERAPIE 2008. [PMCID: PMC7122695 DOI: 10.1007/978-3-540-33129-2_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.
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Kojima M, Hayano J, Tokudome S, Suzuki S, Ibuki K, Tomizawa H, Nakata A, Seno H, Toriyama T, Kawahara H, Furukawa TA. Independent associations of alexithymia and social support with depression in hemodialysis patients. J Psychosom Res 2007; 63:349-56. [PMID: 17905041 DOI: 10.1016/j.jpsychores.2007.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Revised: 04/02/2007] [Accepted: 04/03/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The influences of alexithymia and social support on depression among chronically ill patients were examined prospectively. METHODS The study population was 230 outpatients receiving chronic hemodialysis (HD) therapy. The Beck Depression Inventory-II (BDI-II), the 20-item Toronto Alexithymia Scale (TAS-20), and two subscales of the Social Support Questionnaire were given to the subjects. The BDI-II was readministered after a 6-month interval, and subjects who showed deterioration in their depression score above the level predicted from their baseline score were identified. Multivariate logistic analysis adjusted for age, gender, cause of dialysis, and psychosocial variables were performed. RESULTS Baseline depression was significantly and independently associated with alexithymia and low satisfaction with available support. Deterioration of depression after 6 months was predicted by alexithymia and poor available support. CONCLUSIONS Alexithymia and reduced social support might have independent associations with the presence and the prognosis of depression among HD patients.
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Affiliation(s)
- Masayo Kojima
- Department of Health Promotion and Preventive Medicine, Nagoya City University Graduate School of Medical Science, Nagoya, Aichi, Japan.
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Virtanen M, Vahtera J, Pentti J, Honkonen T, Elovainio M, Kivimäki M. Job strain and psychologic distress influence on sickness absence among Finnish employees. Am J Prev Med 2007; 33:182-7. [PMID: 17826576 DOI: 10.1016/j.amepre.2007.05.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 04/30/2007] [Accepted: 05/08/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Work stress is a recognized risk factor for mental health disorders, but it is not known whether work stress is associated with the morbidity among individuals with psychologic distress. Another shortcoming in earlier research is related to common method bias-the use of individual perceptions of both work stress and psychologic distress. This prospective study was assessed using the General Health Questionnaire (GHQ-12), which identified psychologic distress as a predictor of sickness absence and the effect of work-unit measures of job strain on sickness absence among cases. METHODS Survey data were collected on work stress, indicated by high job strain, for a cohort of public sector employees (6,663 women, 1,323 men), aged 18 to 62 at baseline in 2000-2002, identified as GHQ-12 cases. Coworker assessments of job strain were used to control for bias due to response style. A 2-year follow-up included recorded long-term (>7 days) medically certified sickness absence. Adjustments were made for age, socioeconomic position, baseline chronic physical disease, smoking, and heavy alcohol consumption. RESULTS Cases with psychologic distress had 1.3 to 1.4 times higher incidence of long-term sickness absence than non cases. Among cases, high job strain predicted sickness absence (hazard ratio 1.17 in women, 1.41 in men). The significant effect of job strain on sickness absence was found among workers in high socioeconomic positions (hazard ratio 1.54 for women, 1.58 for men) but not among employees in low socioeconomic positions (hazard ratio 1.06 for women, 1.31 for men). CONCLUSIONS Psychologic distress has an independent effect on medically certified sickness absence. The identification of employees with high job strain and the improvement of their working conditions should be considered as an important target in the prevention of adverse consequences of psychologic distress.
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Affiliation(s)
- Marianna Virtanen
- Finnish Institute of Occupational Health, Topeliuksenkatu, Helsinki, Finland.
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Serretti A, Kato M, Kennedy JL. Pharmacogenetic studies in depression: a proposal for methodologic guidelines. THE PHARMACOGENOMICS JOURNAL 2007; 8:90-100. [PMID: 17684474 DOI: 10.1038/sj.tpj.6500477] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pharmacogenetic studies in mood disorders are rapidly proliferating after the initial reports linking gene variants to treatment outcomes. However, a considerable range of methodologies has been used, making it difficult to compare results across studies and limiting the representativeness of findings. Specification of sampling source (inpatients vs outpatients, primary vs tertiary settings), standardization of diagnostic systems and treatments, adequate monitoring of compliance through plasma levels, sufficient length of observation (at least 6 weeks for acute antidepressant treatments, though 3-6 months are preferable), the use of a range of response criteria and the inclusion of possible environmental confounding variables (life events, social support, temperament) are all potentially important issues when planning pharmacogenetic studies. We reviewed the state-of-the-art methodology and suggested possible guideline for future studies.
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Affiliation(s)
- A Serretti
- Institute of Psychiatry, University of Bologna, Bologna, Italy.
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Lin CH, Chen YS, Lin CH, Lin KS. Factors affecting time to rehospitalization for patients with major depressive disorder. Psychiatry Clin Neurosci 2007; 61:249-54. [PMID: 17472592 DOI: 10.1111/j.1440-1819.2007.01662.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Major depressive disorder is a common psychiatric condition. Hospitalization is usually indicated for patients with more severe symptoms and severe functional impairment. Rehospitalization is known as the re-emergence of significant depressive symptoms. The purpose of the present study was to investigate the risk factors affecting time to rehospitalization. Rehospitalization status was monitored for all patients with major depressive disorder discharged from Kai-Suan Psychiatric Hospital between 1 January 2002 and 31 December 2003. Patients were followed up with respect to rehospitalization until 31 December 2004. The Kaplan-Meier method was used to calculate the median time to rehospitalization. Risk factors associated with rehospitalization were examined on Cox proportional hazards regression. Three hundred patients were recruited. Median time to readmission was 174 days (SD = 37). Comorbid alcohol abuse/dependence (hazard ratio [HR] = 1.841, 95% confidence interval [CI] = 1.229-2.758, P < 0.01), comorbid personality disorders (HR = 1.530, 95%CI = 1.053-2.223, P < 0.05), and the number of previous hospitalizations (HR = 1.121, 95%CI = 1.056-1.190, P < 0.001) were found to be predictors of the shorter time to rehospitalization over the 360-day study. Further research should be carried out to test risk factors in a prospective study, and to study the cost-effectiveness of interventions to reduce risk factors and rehospitalizations.
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Shahar G, Blatt SJ, Zuroff DC. Satisfaction with Social Relations Buffers the Adverse Effect of (Mid–Level) Self–Critical Perfectionism in Brief Treatment for Depression. JOURNAL OF SOCIAL AND CLINICAL PSYCHOLOGY 2007. [DOI: 10.1521/jscp.2007.26.5.540] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Poutanen O, Mattila A, Seppälä NH, Groth L, Koivisto AM, Salokangas RKR. Seven-year outcome of depression in primary and psychiatric outpatient care: results of the TADEP (Tampere Depression) II Study. Nord J Psychiatry 2007; 61:62-70. [PMID: 17365791 DOI: 10.1080/08039480601135140] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The objective of this article was to determine a 7-year naturalistic progression of depression as well as a number of potential prognostic factors among Finnish primary care and psychiatric care patients. Depression-screened patients from primary care and psychiatric care, aged 18-64, were interviewed in 1991-92 with the Present State Examination (PSE) as the diagnostic instrument. The patients were re-contacted in 1998-99, and their depression at final assessment (FinalA) and during the follow-up period (F-up) was assessed by telephone interview using the Composite International Diagnostic Interview--Short Form (CIDI-SF). 250 primary care (58.1%) and 170 (40.2%) psychiatric care patients were successfully followed. Of the primary care patients with severe depression at baseline, 42.4% had had depression during F-up and 21.2% had depression at FinalA. For the patients with mild depression at baseline, the corresponding figures were nearly the same, but for the patients with depressive symptoms clearly lower. Of the psychiatric care patients with severe depression at baseline, 61.0% had had depression during F-up and 26.2% had depression at FinalA. As with primary care patients, the corresponding figures were nearly the same for mild depression at baseline but clearly lower for depressive symptoms. Experienced lifetime mood elevation was associated with having depression during F-up in both primary care and psychiatric care patients. High Depression Scale (DEPS) score at baseline was associated with having depression at FinalA in primary care patients, but in psychiatric care patients, it was the high Hamilton Rating Scale for depression (HAM-D) and drinking problems. Severe depression and mild depression are predictive for subsequent depression at both levels of care. The long-term prognosis for depression is better in primary care. DEPS and HAM-D are useful, prognostic instruments.
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Affiliation(s)
- O Poutanen
- University of Tampere, Medical School/Tampere University Hospital, Psychiatric Clinic, Tampere, Finland.
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Perahia DGS, Kajdasz DK, Royer MG, Walker DJ, Raskin J. Duloxetine in the treatment of major depressive disorder: an assessment of the relationship between outcomes and episode characteristics. Int Clin Psychopharmacol 2006; 21:285-95. [PMID: 16877900 DOI: 10.1097/00004850-200609000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Duloxetine, an inhibitor of serotonin and norepinephrine reuptake, has been approved for the treatment of major depressive disorder. In this analysis, data from eight, double-blind, placebo-controlled duloxetine trials were pooled, and the response to duloxetine treatment (40-120 mg/day) was compared between patients experiencing their first episode of depression (n=581) or a subsequent episode (n=1321), and between patients experiencing a depressive episode of short (n=596), medium (n=669), or long (n=649) duration based on tertile divisions. Treatment response was determined on the basis of changes from baseline in the 17-item Hamilton Rating Scale for Depression total score, the Clinical Global Impressions of Severity Scale, and painful physical symptoms (Somatic Symptom Inventory and Visual Analog Scales). Overall, changes on all outcome measures and response and remission rates were significantly greater in duloxetine-treated patients than in placebo-treated patients. Furthermore, the effect of duloxetine was similar across all episode characteristic groups (first/subsequent episode, short/medium/long episode duration). Only for the Somatic Symptom Inventory was the effect of duloxetine significantly different between groups (greater in the subsequent episode group than in the first episode group). Duloxetine was effective in the treatment of first and subsequent episodes of major depressive disorder, and regardless of duration of the current depressive episode.
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Raphael KG, Janal MN, Nayak S, Schwartz JE, Gallagher RM. Psychiatric comorbidities in a community sample of women with fibromyalgia. Pain 2006; 124:117-25. [PMID: 16698181 DOI: 10.1016/j.pain.2006.04.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Revised: 03/15/2006] [Accepted: 04/03/2006] [Indexed: 12/12/2022]
Abstract
Prior studies of careseeking fibromyalgia (FM) patients often report that they have an elevated risk of psychiatric disorders, but biased sampling may distort true risk. The current investigation utilizes state-of-the-art diagnostic procedures for both FM and psychiatric disorders to estimate prevalence rates of FM and the comorbidity of FM and specific psychiatric disorders in a diverse community sample of women. Participants were screened by telephone for FM and MDD, by randomly selecting telephone numbers from a list of households with women in the NY/NJ metropolitan area. Eligible women were invited to complete physical examinations for FM and clinician-administered psychiatric interviews. Data were weighted to adjust for sampling procedures and population demographics. The estimated overall prevalence of FM among women in the NY/NJ metropolitan area was 3.7% (95% CI=3.2, 4.4), with higher rates among racial minorities. Although risk of current MDD was nearly 3-fold higher in community women with than without FM, the groups had similar risk of lifetime MDD. Risk of lifetime anxiety disorders, particularly obsessive compulsive disorder and post-traumatic stress disorder, was approximately 5-fold higher among women with FM. Overall, this study found a community prevalence for FM among women that replicates prior North American studies, and revealed that FM may be even more prevalent among racial minority women. These community-based data also indicate that the relationship between MDD and FM may be more complicated than previously thought, and call for an increased focus on anxiety disorders in FM.
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Affiliation(s)
- Karen G Raphael
- University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Department of Psychiatry, Newark, NJ 07103, USA.
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Moses T, Leuchter AF, Cook I, Abrams M. Does the clinical course of depression determine improvement in symptoms and quality of life? J Nerv Ment Dis 2006; 194:241-8. [PMID: 16614544 DOI: 10.1097/01.nmd.0000207358.15230.80] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical course factors characterizing individuals' history with depression may be helpful in predicting treatment-related change in quality of life (QOL). Such factors have been studied in relation to symptomatic change with mixed results. This 9-week single-blind treatment trial using reboxetine (1 week placebo lead-in) evaluated the impact of age of onset, history of antidepressant treatment, duration of index episode, number of past episodes, and the presence of precipitating stress on depressed individuals' treatment response. We found that QOL did not normalize along with clinical remission in all areas. Using multivariate analysis, we found that age of onset, history with antidepressants, and the presence of identifiable precipitating stress were all significant predictors of QOL change (controlling for symptomatic change); some factors also predicted symptomatic improvement. Our results support the trend of distinguishing between treatment-related change in QOL and symptomatic change and suggest clinical course factors as promising predictors of QOL.
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Affiliation(s)
- Tally Moses
- School of Social Work, University of Wisconsin-Madison, Madison, Wisconsin 53706, USA
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Newton-Howes G, Tyrer P, Johnson T. Personality disorder and the outcome of depression: meta-analysis of published studies. Br J Psychiatry 2006; 188:13-20. [PMID: 16388064 DOI: 10.1192/bjp.188.1.13] [Citation(s) in RCA: 268] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is conflicting evidence about the influence of personality disorder on outcome in depressive disorders. AIMS Meta-analysis of studies in which a categorical assessment of personality disorder or no personality disorder was made in people with depressive disorders, and categorical outcome (recovered/not recovered) also determined. METHOD Systematic electronic search of the literature for relevant publications. Hand searches of Journal of Affective Disorders and recent reviews, with subsequent meta-analysis of selected studies. RESULTS Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder (random effects model OR=2.18, 95% CI 1.70-2.80), a robust finding maintained with only Hamilton-type depression criteria at outcome (OR=2.20, 95% CI 1.61-3.01). All treatments apart from electroconvulsive therapy (ECT) showed this poor outcome, and the ECT group was small. CONCLUSIONS Combined depression and personality disorder is associated with a poorer outcome than depression alone.
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Affiliation(s)
- Giles Newton-Howes
- Department of Psychological Medicine, Division of Neuroscience and Mental Health, Imperial College London, St Dunstan's Road, London W6 8RP, UK
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Trivedi MH, Morris DW, Pan JY, Grannemann BD, John Rush A. What moderator characteristics are associated with better prognosis for depression? Neuropsychiatr Dis Treat 2005; 1:51-7. [PMID: 18568124 PMCID: PMC2426815 DOI: 10.2147/nedt.1.1.51.52298] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [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
A retrospective data analysis was conducted to evaluate the usefulness of baseline characteristics in predicting treatment response to antidepressant medication in 97 outpatients with nonpsychotic major depression treated for up to sixteen weeks with nefazodone. Baseline demographics (gender), illness features (symptom severity, length of illness, length of current episode, number of episodes, age of onset, longitudinal subtype, endogenicity, melancholia, family history of mood disorders), and social features (living status) were evaluated. Response to treatment was defined as a >/= 50% reduction in the 17-item Hamilton Rating Scale for Depression (HRSD(17)) score. The results of a survival analysis indicated that patients with shorter histories of illness (< 4 years), a negative family history of depression, and those who were either married or were living with someone were more likely to have a positive outcome during the acute phase treatment of depression. The main findings are consistent with extensive previous literature indicating a better short-term outcome of depression where illness is shorter, where there is no family history, and where there is better social support.
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Affiliation(s)
- Madhukar H Trivedi
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Rush AJ, Trivedi M, Carmody TJ, Biggs MM, Shores-Wilson K, Ibrahim H, Crismon ML. One-year clinical outcomes of depressed public sector outpatients: a benchmark for subsequent studies. Biol Psychiatry 2004; 56:46-53. [PMID: 15219472 DOI: 10.1016/j.biopsych.2004.04.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2003] [Revised: 04/13/2004] [Accepted: 04/19/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The symptomatic outcomes of a cohort of public mental health sector depressed outpatients treated for 1 year are described to provide a benchmark for future long-term trials. Baseline moderators of outcome were evaluated. METHODS Outpatients with nonpsychotic major depressive disorder (n = 118) scoring >/=30 on the 30-item Inventory of Depressive Symptomatology-Clinician Rating (IDS-C(30)) were treated with a medication algorithm and patient/family education package. Response and remission rates were assessed every 3 months with the IDS-C(30). Logistic regression analyses evaluated several baseline features in relation to outcome. RESULTS While response and remission rates increased from 3 to 12 months, the 1-year last observation carried forward (LOCF) response (26.3%) and remission (11.0%) rates were not impressive (sustained response = 14.4%; sustained remission = 5.1%). Younger patients and those with full-time employment (at baseline) were more likely to respond. A shorter length of illness tended to be associated with higher response and remission rates (p <.10). Results are generalizable to public sector patients with substantial socioeconomic, general medical, and educational disadvantages who were sufficiently depressed to recommend a change in antidepressant medication. CONCLUSIONS Response and remission rates were modest when compared with outcomes in shorter duration efficacy trials in depressed outpatients with less chronicity, fewer concurrent general medical conditions, and less treatment resistance. Results support the need for more powerful treatments and/or the better delivery of available treatments.
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Affiliation(s)
- A John Rush
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Fleck MPDA, Lafer B, Sougey EB, Del Porto JA, Brasil MA, Juruena MF. [Guidelines of the Brazilian Medical Association for the treatment of depression (complete version)]. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2003; 25:114-22. [PMID: 12975710 DOI: 10.1590/s1516-44462003000200013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Depression is a frequent and chronic condition with high levels of functional disability. Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present the original document that originated the abbreviated version available at the electronic address of Brazilian Medical Association. METHODS This paper was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. Brazilian Medical Association proposed this methodology for the whole project. RESULTS The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Planning of different phases of treatment is22 also discussed. CONCLUSIONS Guidelines are a good tool helping clinical decisions and are a reference for an attitude based on levels of evidence.
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Affiliation(s)
- Marcelo Pio de Almeida Fleck
- Programa de Transtornos de Humor do Hospital de Clínicas de Porto Alegre. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil.
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Abstract
Treatment-resistant depression (TRD) continues to represent a major challenge for treating clinicians. This report reviews the relevant literature to evaluate whether TRD can be considered a specific subtype of depression based on 1) clinical characteristics and course (behavioral phenotype), 2) neurobiological profile, and 3) context and environment in which TRD develops. Although patients with TRD share a number of clinical, neurobiological, and context and environment characteristics, the lack of available data and the clinical heterogeneity of this condition do not currently permit the classification of TRD as a unique subtype of depression; however, this topic is worthy of further evaluation and research. Performing genetics and neuroimaging studies on patients enrolled in large, prospective and controlled studies may provide enough data for classifying TRD (or at least a part of what is currently described as TRD) as a specific subtype of depression. This in turn may facilitate the identification of more effective treatment strategies.
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Affiliation(s)
- Andrea Fagiolini
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Herman S, Blumenthal JA, Babyak M, Khatri P, Craighead WE, Krishnan KR, Doraiswamy PM. Exercise therapy for depression in middle-aged and older adults: Predictors of early dropout and treatment failure. Health Psychol 2002. [DOI: 10.1037/0278-6133.21.6.553] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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DeBattista C, Mueller K. Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder? J ECT 2001; 17:91-8. [PMID: 11417933 DOI: 10.1097/00124509-200106000-00002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among the more common current indications for electroconvulsive therapy (ECT) is treatment-resistant depression. Treatment resistance is correlated with a number of factors, including the presence of comorbid personality disorders, such as borderline personality disorder (BPD). A detailed review of the literature was undertaken and very few reports or studies have dealt specifically with ECT in borderline patients. Thirteen original reports on ECT outcome in personality disordered patients were identified. Depressed patients with a personality disorder, particularly BPD, may have a poorer outcome on some measures. However, the available data suggests that depression in these patients can be effectively treated with ECT. The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not. Unfortunately, the literature is limited by lack of rigorous randomized treatment studies, lack of long-term follow-up, and other methodological weaknesses. Clinical guidelines are suggested.
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Affiliation(s)
- C DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, California 94035-5723, USA
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Brown C, Schulberg HC, Prigerson HG. Factors associated with symptomatic improvement and recovery from major depression in primary care patients. Gen Hosp Psychiatry 2000; 22:242-50. [PMID: 10936631 DOI: 10.1016/s0163-8343(00)00086-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article describes a post-hoc analysis of clinical and psychosocial factors and beliefs about health associated with treatment outcome in a sample of depressed primary care patients (N=181) randomly assigned to a standardized treatment or physician's usual care (UC). Different factors were found to predict clinical outcomes for treatment modality [UC vs. interpersonal psychotherapy (IPT) or nortriptyline (NT)] and the type of outcome evaluated (i.e., depressive symptoms at 8 months or symptomatic and functional recovery at 8 months). Factors associated with treatment-specific outcomes are also described. Consistent with prior studies, lower depressive symptom severity at 8 months was associated with higher baseline functioning, minimal medical co-morbidity, race, and standardized pharmacologic or psychotherapeutic treatment. Additionally, an interaction between treatment modality and health locus of control indicated that individuals perceiving more self-control of their health and who received a standardized treatment experienced greater depressive symptom reduction at 8 months. Factors associated with symptomatic and functional recovery from the depressive episode were also examined. Patients who received a standardized treatment (IPT or NT) perceived greater control of their health and lacked a lifetime generalized anxiety disorder or panic disorder were more likely to recover by month 8 than those who received usual care. While clinical severity and treatment adequacy play an important role in both symptomatic improvement and full recovery from a depressive episode, other key factors such as health beliefs and non-depressive psychopathology also influence recovery.
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Affiliation(s)
- C Brown
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA
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Abstract
The objective of this study was to evaluate the frequency and consequences of the presence of residual symptoms in patients treated for major depression. The literature specifically focused on recovery and residual symptomatology of depression was reviewed. Thirty per cent or more of treated patients present residual symptoms. These symptoms appear to be associated with a higher frequency and larger number of relapses and equally affect the outcome of depression in different age groups. They also seem to have a major impact on work and psychosocial functioning because of cognitive dysfunction and a reduction in social interaction affecting patients' quality of life. We found that there is scant literature on residual symptoms contrasting with the profuse reports on single or multiple antidepressant drug trials. Studies focusing on this important issue in the treatment of depression are needed.
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Affiliation(s)
- H Silva
- Faculty of Medicine, Universidad de Chile
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Anderson IM, Nutt DJ, Deakin JF. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology. J Psychopharmacol 2000; 14:3-20. [PMID: 10757248 DOI: 10.1177/026988110001400101] [Citation(s) in RCA: 271] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.
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Affiliation(s)
- I M Anderson
- University of Manchester Department of Psychiatry, University of Manchester, UK.
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