Trajectory classes of depression in a randomized depression trial of heart failure patients: a reanalysis of the SADHART-CHF trial

Antidepressant Response Trajectories and Associated Clinical Prognostic Factors Among Older Adults

IMPORTANCE

More than 50% of older adults with late-life major depressive disorder fail to respond to initial treatment with first-line pharmacological therapy.

OBJECTIVES

To assess typical patterns of response to an open-label trial of extended-release venlafaxine hydrochloride (venlafaxine XR) for late-life depression and to evaluate which clinical factors are associated with the identified longitudinal response patterns.

DESIGN, SETTING, AND PARTICIPANTS

Group-based trajectory modeling was applied to data from a 12-week open-label pharmacological trial conducted in specialty care as part of the Incomplete Response in Late Life: Getting to Remission Study. Clinical prognostic factors, including domain-specific cognitive performance and individual depression symptoms, were examined in relation to response trajectories. Participants included 453 adults aged 60 years or older with current major depressive disorder. The study was conducted between August 2009 and August 2014.

INTERVENTION

Open-label venlafaxine XR (titrated up to 300 mg/d) for 12 weeks.

MAIN OUTCOMES AND MEASURES

Subgroups exhibiting similar response patterns were derived from repeated measures of overall depression severity obtained using the Montgomery-Asberg Depression Rating Scale.

RESULTS

Among the 453 study participants, 3 subgroups with differing baseline depression severity clearly responded to treatment: one group with the lowest baseline severity had a rapid response (n = 69 [15.23%]), and distinct responses were also apparent among groups starting at moderate (n = 108 [23.84%]) and higher (n = 25 [5.52%]) baseline symptom levels. Three subgroups had nonresponding trajectories: 2 with high baseline symptom levels (totaling 35.98%: high, nonresponse 1, n = 110 [24.28%]; high, nonresponse 2, n = 53 [11.70%]) and 1 with moderate baseline symptom levels (n = 88 [19.43%]). Several factors were independently associated with having a nonresponsive trajectory, including greater baseline depression severity, longer episode duration, less subjective sleep loss, more guilt, and more work/activity impairment (P < .05). Higher delayed memory (list recognition) performance was independently associated with having a rapid response (adjusted odds ratio = 2.22; 95% CI, 1.18-4.20).

CONCLUSIONS AND RELEVANCE

Based on the observed trajectory patterns, patients who have late-life depression with high baseline depression severity are unlikely to respond after 12 weeks of treatment with venlafaxine XR. However, high baseline depression severity alone may be neither a necessary nor sufficient predictor of treatment nonresponse.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00892047.

Identifying depressive symptom trajectory groups among Korean adults and psychosocial factors as group determinants

BACKGROUND

Longitudinal research is needed to examine the depressive symptom trajectories of different groups during adulthood and their antecedents and consequences, because depressive symptoms may be changeable and heterogeneous over time.

AIMS

This study examined the number of trajectory groups describing the depressive symptoms of Korean adults, as well as the shape of the trajectories and the association between trajectory group membership and psychosocial factors identified based on the ecosystem model.

METHOD

This study used Nagin's semi-parametric group-based modeling to analyze Year 1 to Year 7 data from Korea Welfare Panel Survey (N = 13,735), a nationally representative sample of community-dwelling adults.

RESULTS

Three distinct trajectory groups were identified: a low stable depressive symptoms group, a moderate depressive symptoms group and a high depressive symptoms group. Result from multinominal logit analysis showed that all psychosocial factors except family relationships affected the likelihood of membership in the three depressive symptoms groups. Especially, self-esteem was the psychosocial factor with the largest impact on depressive symptom trajectory group membership. When screening for depressive symptoms, individuals with a low socioeconomic status should be a primary concern and intervention should be made available to them.

CONCLUSION

Prevention or intervention with members of the identified trajectory groups would likely require integrative approaches targeting psychosocial factors across multiple contexts.

Data-driven course trajectories in primary care patients with major depressive disorder

BACKGROUND

The chronic nature of MDD has been acknowledged as one of the key determinants of the burden associated with depression. Unfortunately, so far described prognostic factors have been inconsistent, possibly due to used course outcomes that are often based on arbitrary criteria/cut-offs. Therefore, the aim of the current study was to use data-driven trajectory groups based on closely spaced weekly severity ratings, as outcomes in prognostic research.

METHODS

The sample consisted of primary care patients with MDD (n = 153), who were followed up for a year with 52 consecutive weekly ratings of the nine DSM-IV MDD criterion symptoms. Growth Mixture Modeling (GMM) was used to reduce the interpersonal growth variation to an optimal set of clinically interpretable trajectory groups. Next, baseline course predictors were investigated and the prognostic (added) value of course-group membership was investigated for clinical outcomes after 1, 2, and 3 years.

RESULTS

GMM resulted in four trajectory groups: "early remission" (40.2%), "late remission" (9.8%), "remission and recurrence" (17.0%), and "chronic" (33.0%). Multivariate predictors of "chronic" group membership were a prior suicide attempt, comorbid dysthymia, and lower levels of somatic depressive symptoms. Group membership predicted differences in depression severity and/or quality of life after 1, 2, and 3 years.

CONCLUSIONS

The used data-driven approach provided a parsimonious and clinically informative way to describe course variation across MDD patients. Using the trajectory groups to investigate prognostic factors of MDD provided insight in potentially useful prognostic factors. Importantly, trajectory-group membership was itself a strong predictor of future mental well-being.

Trajectories of change in anxiety severity and impairment during and after treatment with evidence-based treatment for multiple anxiety disorders in primary care

BACKGROUND

Coordinated Anxiety Learning and Management (CALM) is a model for delivering evidence-based treatment for anxiety disorders in primary care. Compared to usual care, CALM produced greater improvement in anxiety symptoms. However, mean estimates can obscure heterogeneity in treatment response. This study aimed to identify (1) clusters of participants with similar patterns of change in anxiety severity and impairment (trajectory groups); and (2) characteristics that predict trajectory group membership.

METHODS

The CALM randomized controlled effectiveness trial was conducted in 17 primary care clinics in four US cities in 2006-2009. 1,004 English- or Spanish-speaking patients age 18-75 with panic, generalized anxiety, social anxiety, and/or posttraumatic stress disorder participated. The Overall Anxiety Severity and Impairment Scale was administered repeatedly to 482 participants randomized to CALM treatment. Group-based trajectory modeling was applied to identify trajectory groups and multinomial logit to predict trajectory group membership.

RESULTS

Two predicted trajectories, representing about two-thirds of participants, were below the cut-off for clinically significant anxiety a couple of months after treatment initiation. The predicted trajectory for the majority of remaining participants was below the cut-off by 9 months. A small group of participants did not show consistent improvement. Being sicker at baseline, not working, and reporting less social support were associated with less favorable trajectories.

CONCLUSIONS

There is heterogeneity in patient response to anxiety treatment. Adverse circumstances appear to hamper treatment response. To what extent anxiety symptoms improve insufficiently because adverse patient circumstances contribute to suboptimal treatment delivery, suboptimal treatment adherence, or suboptimal treatment response requires further investigation.

Psycho-emotional manifestations of valvular heart diseases: prospective assessment in mitral regurgitation

OBJECTIVE

To define the prevalence and consequences of post-traumatic stress disorder (PTSD) as an emotional response to cardiac diseases in patients with mitral regurgitation.

METHODS

We prospectively enrolled 186 patients with moderate or severe organic mitral regurgitation, presenting class I (absent) or II (minimal) dyspnea, who were compared with 80 controls of similar age (38 with completely normal cardiac function; 42 with mild mitral-valve prolapse; all with no, or at most mild, mitral regurgitation). Mitral-regurgitation severity and consequences were comprehensively measured, simultaneously with PTSD, anxiety, and depression.

RESULTS

PTSD prevalence was higher in mitral-regurgitation patients vs controls (23% vs 9%, P <.01). Although mitral-regurgitation objective severity (regurgitant volume 77.8 ± 28.9 vs 79.0 ± 27.5 mL, P = .8) and objective consequences (left-atrial volume 59.1 ± 20.9 vs 54.02 ± 15.6 mL, P = .1; right-ventricular systolic pressure 34.1 ± 11.4 vs 32.9 ± 7.2 mm Hg, P = .6) were similar with and without PTSD (all P ≥.1), patients with PTSD were more symptomatic (class II 74 vs 38%; fatigue 71% vs 38%, both P <.0001) and had higher anxiety and depressions scores (P <.0001).

CONCLUSIONS

PTSD is prevalent in organic moderate or severe mitral-regurgitation patients but is not determined by objective mitral-regurgitation severity or consequences. PTSD is linked to anxiety and depression and to symptoms usually considered cardiac, such as dyspnea. Thus, PTSD and psycho-emotional manifestations, linked to symptoms, represent important responses to chronic-valve disease that may affect clinical outcomes.

A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care

BACKGROUND

Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care.

METHODS

789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months.

RESULTS

Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables.

LIMITATIONS

Adult only cohort, self-report measures.

CONCLUSIONS

Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.

Time-course of depressive symptoms in patients with heart failure

BACKGROUND

It is unclear how depressive symptoms in patients with heart failure develop over time and whether this trajectory of depressive symptoms is associated with hospital admission and prognosis.

AIM

To describe the time-course of depressive symptoms and determine the relationship with hospitalisation and mortality.

METHOD

Data was analysed using 611 patients with completed CES-D questionnaires at baseline and at 18 months. Data on hospitalisation was collected 18 months after discharge and data on mortality was collected 18 and 36 months post-discharge.

RESULTS

A total of 140 (61%) of the 229 patients with depressive symptoms at discharge had recovered from depressive symptoms after 18 months whereas 71 (18%) of the 382 non-depressed developed depressive symptoms and 89 (39%) of the 229 depressed remained depressed. Patients with recently (i.e. during the last 18 months) developed depressive symptoms showed a significantly higher risk for cardiovascular hospitalisation (HR 1.7, 95% CI 1.1-2.6, P=.016). After 36 months, patients with developed depressive symptoms after discharge were at a higher risk of all-cause mortality (HR 2.0, 95% CI 1.2-3.5, P=.012) and there was a trend towards a higher risk of all-cause mortality in patients with ongoing depressive symptoms (HR 1.7, 95% CI 0.98-3.1, P=.056).

CONCLUSION

A significant proportion of patients with HF, who were reported depressive symptoms at discharge recovered from depressive symptoms during the following 18 months. However, patients who remained having depressive symptoms or patients who developed depressive symptoms had a worse prognosis.