Baseline depression severity as a predictor of single and combination antidepressant treatment outcome: results from the CO-MED trial

'Does it matter how old I feel?' The role of subjective age in a psychosocial intervention for improving depressive symptomatology among older adults in Brazil (PROACTIVE)

OBJECTIVES

Depression is a prevalent mental health condition that also often affects older adults. The PROACTIVE psychosocial intervention was developed to reduce depressive symptomatology among older adults within primary care settings in Brazil. An important psychological marker that affects individuals' aging experience relates to how old people feel. Known as subjective age, this marker has been shown to be a risk factor for experiencing greater depressive symptoms if individuals report feeling older than their (chronological) age. In this study, we perform secondary analyses of the PROACTIVE cluster-randomized controlled trial to examine the role of subjective age.

METHOD

The sample included 715 Brazilian older adults (74% female, Mage 68.6, SD = 6.9, age range: 60-94 years) randomized to intervention (n = 360, 74% female, Mage 68.4, SD = 6.6, age range: 60-89 years) or control (n = 355, 74% female, Mage 68.9, SD = 7.2, age range: 60-94 years) arms. Here our primary outcome was depressive symptoms at the 8-month follow-up assessed with the 9-item Patient Health Questionnaire (PHQ-9) as a continuous variable. Our previous analyses demonstrated improved recovery from depression at follow-up in the intervention compared with the control arm.

RESULTS

Relevant main effects and interactions in regression models for PHQ-9 presented here found that those reporting older subjective age had worse depressive symptoms at follow-up but that they benefitted more from the intervention when initial levels of depression were high. For participants who reported younger subjective ages the intervention showed positive effects that were independent of initial levels of depression.

CONCLUSION

Our findings emphasize the importance of investigating possible underlying mechanisms that can help clarify the impact of mental health interventions.

Predictors of remission after repetitive transcranial magnetic stimulation for the treatment of late-life depression

Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment in patients with depression, yet treatment response remains variable. While previous work has identified predictors of remission in younger adults, relatively little data exists in late-life depression (LLD). To address this gap, data from 164 participants with LLD from a randomized non-inferiority treatment trial comparing standard bilateral rTMS to bilateral theta burst stimulation (TBS) (ClinicalTrials.gov identifier: NCT02998580) were analyzed using binary logistic regression and conditional inference tree (CIT) modeling. Lower baseline depression symptom severity, fewer prior antidepressant treatment failures, and higher global cognition predicted remission following rTMS treatment. The CIT predicted a higher likelihood of achieving remission for patients with a total score of 19 or lower on the Montgomery-Åsberg Depression Rating Scale, 1 or fewer prior antidepressant treatment failures, and a total score of 23 or higher on the Montreal Cognitive Assessment. Our results indicate that older adults with lower severity of depression, fewer antidepressant treatment failures, and higher global cognition benefit more from current forms of rTMS. The results suggest that there is potentially higher value in using rTMS earlier in the treatment pathway for depression in older adults.

Estimating the prognostic value of cross-sectional network connectivity for treatment response in depression

BACKGROUND

Tightly connected symptom networks have previously been linked to treatment resistance, but most findings come from small-sample studies comparing single responder v. non-responder networks. We aimed to estimate the association between baseline network connectivity and treatment response in a large sample and benchmark its prognostic value against baseline symptom severity and variance.

METHODS

N = 40 518 patients receiving treatment for depression in routine care in England from 2015-2020 were analysed. Cross-sectional networks were constructed using the Patient Health Questionnaire-9 (PHQ-9) for responders and non-responders (N = 20 259 each). To conduct parametric tests investigating the contribution of PHQ-9 sum score mean and variance to connectivity differences, networks were constructed for 160 independent subsamples of responders and non-responders (80 each, n = 250 per sample).

RESULTS

The baseline non-responder network was more connected than responders (3.15 v. 2.70, S = 0.44, p < 0.001), but effects were small, requiring n = 750 per group to have 85% power. Parametric analyses revealed baseline network connectivity, PHQ-9 sum score mean, and PHQ-9 sum score variance were correlated (r = 0.20-0.58, all p < 0.001). Both PHQ-9 sum score mean (β = -1.79, s.e. = 0.07, p < 0.001), and PHQ-9 sum score variance (β = -1.67, s.e. = 0.09, p < 0.001) had larger effect sizes for predicting response than connectivity (β = -1.35, s.e. = 0.12, p < 0.001). The association between connectivity and response disappeared when PHQ-9 sum score variance was accounted for (β = -0.28, s.e. = 0.19, p = 0.14). We replicated these results in patients completing longer treatment (8-12 weeks, N = 22 952) and using anxiety symptom networks (N = 70 620).

CONCLUSIONS

The association between baseline network connectivity and treatment response may be largely due to differences in baseline score variance.

The short-form of the Cyberchondria Severity Scale (CSS-12): Adaptation and validation of the Spanish version in young Peruvian students

BACKGROUND

Cyberchondria is defined as the increase in health-related anxiety or anguish associated with excessive or repeated online searches for health-related information. Our objective was to cross-culturally adapt and validate the CSS-12 scale for Peruvian Spanish speakers, to determine whether the Bifactor model works as well in our population as in previous studies' and to explore whether the Bifactor-ESEM is a more suitable model.

METHODS

We performed a cultural adaptation using the Delphi method and a validation study on medical students between 2018 and 2019. Reliability was evaluated by using Cronbach's alpha (α) and McDonald's omega (Ω) for internal consistency, and Pearson's r and intraclass correlation coefficient (ICC), for test-retest reliability. We evaluated construct validity by contrasting four measurement models for the CSS-12 and the convergent validity against health anxiety.

RESULTS

The Spanish CSS-12 showed excellent reliability (α = .93; Ω = .93; ICC = .93; r = .96). The Bifactor ESEM model showed the best fit, supporting a unidimensional measure of the general cyberchondria. This measure was positively associated with health anxiety (r = .51).

CONCLUSIONS

The Spanish CSS-12 provides a valid and reliable unidimensional measure of cyberchondria, which is distinguishable from the more general health anxiety. This can be applied to similar populations and future research. The Bifactor-ESEM model appears to offer a more accurate and realistic representation of the multifaceted nature of cyberchondria. We provide a free-to-use form of the Spanish CSS-12 as supplemental material.

Factors Affecting Antidepressant Response Trajectories: A Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes Trial Report

Background

In this secondary analysis of the VA Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) study we used antidepressant response trajectories to assess the association of treatment and multiple clinical/demographic factors with the probability of response.

Methods

Using data from VAST-D, a multi-site, randomized, single-blind trial with parallel-assignment to one of three treatment interventions in 1522 Veterans whose major depressive disorder was unresponsive to at least one antidepressant trial, we evaluated response patterns using group-based trajectory modeling (GBTM). A weighted multinomial logistic regression analysis with backward elimination and additional exploratory analyses were performed to evaluate the association of multiple clinical/demographic factors with the probability of inclusion into specific trajectories. Additional exploratory analyses were used to identify factors associated with trajectory group membership that could have been missed in the primary analysis.

Results

GBTM showed the best fit for depression symptom change was comprised of six trajectories, with some trajectories demonstrating minimal improvement and others showing a high probability of remission. High baseline depression and anxiety severity scores decreased, and early improvement increased, the likelihood of inclusion into the most responsive trajectory in both the GBTM and exploratory analyses.

Conclusion

While multiple factors influence responsiveness, the probability of inclusion into a specific depression symptom trajectory is most strongly influenced by three factors: baseline depression, baseline anxiety, and the presence of early improvement.

The course of insomnia symptoms during the acute treatment of major depressive disorder: A CAN-BIND-1 report

Despite considerable efforts to study the relationship between insomnia and depression, there is minimal research investigating whether insomnia symptoms change over time during a course of antidepressant pharmacotherapy. This study investigated the course of insomnia symptoms during the acute treatment of major depressive disorder (MDD) using a secondary analysis of data from MDD patients (N = 180) who were treated with open-label escitalopram (10-20 mg/day) for 8-weeks. Montgomery-Asberg Depression Rating Scale without sleep item (modified-MADRS) assessed depression and Self-reported Quick Inventory Depressive Scale (QIDS-SR) measured subjective sleep-onset, mid-nocturnal, and early-morning insomnia throughout 8-weeks of treatment. Pittsburgh Sleep Quality Index (PSQI) was used to assess subjective sleep quality, duration, onset latency, and efficiency throughout 8-weeks of treatment. Remission of depression was defined as modified-MADRS ≤10 at week-8. Mixed model repeated measures (MMRMs) were conducted with remission status as an independent variable and each sleep variable as a dependent variable. MMRMs demonstrated that remitters had significantly lower QIDS-SR sleep-onset and mid-nocturnal insomnia scores as well as a significantly lower PSQI sleep quality score than non-remitters throughout 8-weeks of treatment. Monitoring subjective sleep-onset and mid-nocturnal insomnia during the course of treatment with serotonergic antidepressants may be useful for predicting acute remission of depression.

Predictors of perceived symptom change with acute cannabis use for mental health conditions in a naturalistic sample: A machine learning approach

BACKGROUND

Despite limited clinical evidence of its efficacy, cannabis use has been commonly reported for the management of various mental health concerns in naturalistic field studies. The aim of the current study was to use machine learning methods to investigate predictors of perceived symptom change across various mental health symptoms with acute cannabis use in a large naturalistic sample.

METHODS

Data from 68,819 unique observations of cannabis use from 1307 individuals using cannabis to manage mental health symptoms were analyzed. Data were extracted from Strainprint®, a mobile app that allows users to monitor their cannabis use for therapeutic purposes. Machine learning models were employed to predict self-perceived symptom change after cannabis use, and SHapley Additive exPlanations (SHAP) value plots were used to assess feature importance of individual predictors in the model. Interaction effects of symptom severity pre-scores of anxiety, depression, insomnia, and gender were also examined.

RESULTS

The factors that were most strongly associated with perceived symptom change following acute cannabis use were pre-symptom severity, age, gender, and the ratio of CBD to THC. Further examination on the impact of baseline severity for the most commonly reported symptoms revealed distinct responses, with cannabis being reported to more likely benefit individuals with lower pre-symptom severity for depression, and higher pre-symptom severity for insomnia. Responses to cannabis use also differed between genders.

CONCLUSIONS

Findings from this study highlight the importance of several factors in predicting perceived symptom change with acute cannabis use for mental health symptom management. Mental health profiles and baseline symptom severity may play a large role in perceived responses to cannabis. Distinct response patterns were also noted across commonly reported mental health symptoms, emphasizing the need for placebo-controlled cannabis trials for specific user profiles.

Adverse childhood experiences and repetitive transcranial magnetic stimulation outcomes for depression

BACKGROUND

History of adverse childhood experiences (ACEs) is associated with poorer treatment outcomes in depression. How ACEs affect outcomes from repetitive transcranial magnetic stimulation (rTMS) is not well-defined. The primary aim was to investigate whether ACEs affect depression outcomes in patients receiving high frequency rTMS, either deep TMS (dTMS) or intermittent theta burst stimulation (iTBS), to the left dorsolateral prefrontal cortex.

METHODS

The Hamilton Depression Rating Scale (HAMD-17) was collected at baseline and every 2 weeks for 4-6 weeks. Outcomes included improvement in HAMD-17 and remission. The ACE-10 questionnaire was used to quantify categories of ACEs. Data from 99 patients with MDD receiving an acute rTMS course were analyzed.

RESULTS

Patients had a mean of 2.4 ACEs (SD 2.5). No significant differences in outcomes were found between dTMS or iTBS so these data were pooled. Using a continuous ACE variable showed no significant impact on outcomes. Using a categorical ACE variable (0, 1, 2, 3, 4 or more) did not reveal significant effects of ACEs on outcomes. Higher ACE was associated with steeper decrease in HAMD-17 only from baseline to week 2 but not at other times.

LIMITATIONS

This was an open-label study. The well-validated ACE questionnaire does not measure severity or frequency of adversities.

CONCLUSIONS

Patients with depression receiving rTMS reported on average 2.4 ACEs. ACE scores may lead to a steeper early decline in HAMD-17 but did not otherwise impact depression outcomes. Presence of high levels of ACEs should not preclude consideration of rTMS for depression.

Daily dynamics of negative affect: indicators of rate of response to treatment and remission from depression?

More instability (MSSD) and variability (SD) of negative affect (NA) have been related to current and future depressive symptoms. We investigated whether NA instability and variability were predictive of the rate of symptom improvement during treatment and of reaching remission status. Forty-six individuals with major depressive disorder completed six days of ecological momentary assessments (10 beeps/day) before starting a combination of pharmacotherapy and supportive therapy. During and after treatment, the Hamilton Depression Rating Scale (HDRS) diagnostic interview was performed monthly for 18 months. The rate of change in HDRS scores over five months (during treatment) and remission status (HDRS ≤ 7) over eighteen months were predicted by the SD, MSSD and Mean of NA, and relevant baseline predictors. Higher Mean NA and baseline symptom severity, but not NA variability or instability, predicted stronger depressive symptom reduction during treatment. Higher odds of remitting were only associated with lower Mean NA. Higher mean NA may indicate more room for improvement and thus for a steeper rate of symptom change, while lower mean NA levels may imply that remission status is more readily reached. To resolve the inconclusive findings for instability and variability as predictors of symptom improvement replication in larger samples is required.

Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis

BACKGROUND

Childhood trauma is a common and potent risk factor for developing major depressive disorder in adulthood, associated with earlier onset, more chronic or recurrent symptoms, and greater probability of having comorbidities. Some studies indicate that evidence-based pharmacotherapies and psychotherapies for adult depression might be less efficacious in patients with a history of childhood trauma than patients without childhood trauma, but findings are inconsistent. Therefore, we examined whether individuals with major depressive disorder, including chronic forms of depression, and a reported history of childhood trauma, had more severe depressive symptoms before treatment, had more unfavourable treatment outcomes following active treatments, and were less likely to benefit from active treatments relative to a control condition, compared with individuals with depression without childhood trauma.

METHODS

We did a comprehensive meta-analysis (PROSPERO CRD42020220139). Study selection combined the search of bibliographical databases (PubMed, PsycINFO, and Embase) from Nov 21, 2013, to March 16, 2020, and full-text randomised clinical trials (RCTs) identified from several sources (1966 up to 2016-19) to identify articles in English. RCTs and open trials comparing the efficacy or effectiveness of evidence-based pharmacotherapy, psychotherapy, or combination intervention for adult patients with depressive disorders and the presence or absence of childhood trauma were included. Two independent researchers extracted study characteristics. Group data for effect-size calculations were requested from study authors. The primary outcome was depression severity change from baseline to the end of the acute treatment phase, expressed as standardised effect size (Hedges' g). Meta-analyses were done using random-effects models.

FINDINGS

From 10 505 publications, 54 trials met the inclusion criteria, of which 29 (20 RCTs and nine open trials) contributed data of a maximum of 6830 participants (age range 18-85 years, male and female individuals and specific ethnicity data unavailable). More than half (4268 [62%] of 6830) of patients with major depressive disorder reported a history of childhood trauma. Despite having more severe depression at baseline (g=0·202, 95% CI 0·145 to 0·258, I2=0%), patients with childhood trauma benefitted from active treatment similarly to patients without childhood trauma history (treatment effect difference between groups g=0·016, -0·094 to 0·125, I2=44·3%), with no significant difference in active treatment effects (vs control condition) between individuals with and without childhood trauma (childhood trauma g=0·605, 0·294 to 0·916, I2=58·0%; no childhood trauma g=0·178, -0·195 to 0·552, I2=67·5%; between-group difference p=0·051), and similar dropout rates (risk ratio 1·063, 0·945 to 1·195, I2=0%). Findings did not significantly differ by childhood trauma type, study design, depression diagnosis, assessment method of childhood trauma, study quality, year, or treatment type or length, but differed by country (North American studies showed larger treatment effects for patients with childhood trauma; false discovery rate corrected p=0·0080). Most studies had a moderate to high risk of bias (21 [72%] of 29), but the sensitivity analysis in low-bias studies yielded similar findings to when all studies were included.

INTERPRETATION

Contrary to previous studies, we found evidence that the symptoms of patients with major depressive disorder and childhood trauma significantly improve after pharmacological and psychotherapeutic treatments, notwithstanding their higher severity of depressive symptoms. Evidence-based psychotherapy and pharmacotherapy should be offered to patients with major depressive disorder regardless of childhood trauma status.

FUNDING

None.

Clinical correlates and prognostic impact of binge-eating symptoms in major depressive disorder

Binge-eating (BE) symptoms are relatively common in major depressive disorder (MDD), but their prognostic role is not fully understood. This study compared two groups of patients with MDD experiencing or not BE symptoms to ascertain differences in terms of clinical manifestations, presence of bipolar features, and antidepressant treatment outcomes. The study involved 482 outpatients collected within the Combining Medications to Enhance Depression Outcomes (CO-MED) trial, who were assessed with scales for depressive and hypomanic symptomatology, suicidality, comorbid mental disorders, and childhood traumas. BE symptoms were reported in 95 patients (20%). Patients with MDD experiencing BE symptoms were characterized by higher scores of negative self-outlook ( P = 0.0018), negative outlook of future ( P = 0.0014), irritability ( P = 0.0043), comorbid anxiety disorders (generalized anxiety disorder: P = 0.0006; panic disorder: P &lt; 0.0001; social phobia: P &lt; 0.0001), obsessive-compulsive disorder ( P = 0.0053), hypomanic symptoms (increased talkativeness: P = 0.0029; reduced need for sleep: P = 0.0171), and suicidality (suicidal propensity: P = 0.0013; suicidal risk: P = 0.0148; lifetime suicidal behavior: P = 0.0052). BE symptoms (OR = 2.02; 95% CI = 1.06-3.84) and depression severity (OR = 1.04; 95% CI = 1.00-1.08) were independently associated with lifetime attempted suicide. The presence of BE symptoms might indicate higher severity of depressive disorder. Suicidal risk is a major issue in these patients, whereas the association between BE and bipolar features needs further research.

Post-traumatic stress disorder and childhood emotional abuse are markers of subthreshold bipolarity and worse treatment outcome in major depressive disorder

Post-traumatic stress disorder (PTSD) and childhood maltreatment (CMT: parental neglect; emotional, physical and sexual abuse) have been linked to bipolar disorder but they are also common in major depressive disorder (MDD). Our objective was to investigate their association with the bipolar spectrum and antidepressant treatment outcome in 482 outpatients with DSM-IV MDD treated in the Combining Medications to Enhance Depression Outcomes trial for 28 weeks Bipolar spectrum score included age of onset <21 years, subthreshold hypomania (a period of elated or irritable mood with at least two concurrent hypomanic symptoms, which did not fulfill DSM criteria for hypomanic/manic episode) and depressive mixed state (DMX). PTSD subjects (n = 107; 22%) had more severe depression (P < 0.0001), work and social impairment (P = 0.0031), comorbid anxiety disorders (P < 0.0001) and increased suicidality (P = 0.0003). Bipolar spectrum score was higher with PTSD comorbidity (P = 0.0063) and childhood emotional abuse (P = 0.0001). PTSD comorbidity was associated with residual suicidality (P = 0.0218) after 6 weeks of antidepressant use whereas childhood emotional abuse [odds ratio (OR), 1.01-2.22], subthreshold hypomania (OR, 1.04-4.09) and DMX (OR, 1.00-4.19) were predictors of mood switch. These results corroborate the role of PTSD and childhood emotional abuse as markers of bipolar spectrum and prognostic factors during antidepressant treatment.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Extra-Virgin Olive Oil Improves Depression Symptoms Without Affecting Salivary Cortisol and Brain-Derived Neurotrophic Factor in Patients With Major Depression: A Double-Blind Randomized Controlled Trial

BACKGROUND

Many patients with depression are reluctant to take psychiatric medications. Hence, complementary therapies such as nutritional considerations could be advantageous. The antidepressant potential of olive oil has been proved in observational studies.

OBJECTIVE

The effect of extra-virgin olive oil (EVOO) on depression symptoms and cortisol and brain-derived neurotrophic factor (BDNF) levels in patients with depression was examined.

DESIGN AND PARTICIPANTS

This was a double-blind randomized controlled trial conducted on 73 patients suffering from major depressive disorder in Shiraz, Iran, in 2016.

INTERVENTION

The patients were randomly assigned to intervention (EVOO) and control (sunflower oil) groups and consumed 25 mL/d of the corresponding oil for 52 days.

MAIN OUTCOME MEASURES

Depression symptoms were assessed by Beck Depression Inventory-II (BDI-II) and 7-item Hamilton Depression Rating Scale (HAMD-7). Salivary cortisol levels were determined immediately after awakening and 30 minutes later. Cortisol awakening response and the area under the curve with respect to ground and increase were computed. Serum BDNF concentrations were also measured.

STATISTICAL ANALYSES PERFORMED

Statistical analysis was conducted based on intention-to-treat and per-protocol approaches. Within-group changes were examined with repeated measures (for BDI-II and HAMD-7) and with paired t test (for other variables). Between-group comparisons were performed with analysis of covariance after adjustment for confounding factors.

RESULTS

In intention-to-treat analysis, HAMD-7 score was the only variable with significant changes within and between groups, the latter as a greater decline in EVOO group (P = .001). BDI-II score did not show significant change in either group but the between-group comparison revealed a significant difference (P = .021). EVOO showed antidepressant effect in severely depressed patients (P = .017 for BDI-II and 0.008 for HAMD-7) but not in mild/moderate depression category. Serum BDNF concentrations, salivary cortisol levels at immediately after awakening (T₀) and 30 minutes later, cortisol awakening response, the area under the curve with respect to ground and increase did not change within or between groups. Results of per-protocol analysis were not different.

CONCLUSIONS

The results of this study suggested beneficial effects of EVOO on depression symptoms in patients with severe depression but not in those with mild to moderate depression. The effects were significant from both statistical and clinical points of view.

Impact of childhood maltreatment on outcomes of antidepressant medication in chronic and/or recurrent depression

BACKGROUND

While childhood maltreatment (CMT) is associated with higher rates of chronicity and recurrence in depression, whether CMT results in poorer outcomes with antidepressant medication remains unclear.

METHODS

We performed secondary analyses with data from the large, representative, multisite trial Combining Medications to Enhance Depression Outcomes (CO-MED). CO-MED was a randomized, single-blinded, placebo-controlled study with 665 individuals (663 assessed for CMT) with chronic and/or recurrent Major Depressive Disorder (MDD). CMT was determined by a brief self-reported questionnaire assessing the four types of CMT defined by the Centers for Disease Control and Prevention: sexual abuse, emotional abuse, physical abuse, and neglect. Repeated measures and logistic regression analyses were used.

RESULTS

Individuals with CMT did not have a differential improvement of depressive symptoms when compared to those without CMT (adjusted p=.203 for continuous analysis; adjusted p=.320 for remission rates). Neither type of antidepressant medication (adjusted p=.302) nor the age at which CMT occurred (adjusted p=.509) affected depressive symptom outcomes. There was no difference in functional improvement between individuals with and without CMT (adjusted p=.228). A history of CMT was associated with greater antidepressant side effects (p=.009).

LIMITATIONS

This study investigated treatment-seeking individuals with chronic and/or recurrent MDD. Intensity and duration of CMT were not assessed.

CONCLUSION

In a sample of treatment-seeking outpatients with chronic and/or recurrent MDD, a history of CMT was not associated with differential symptomatic or functional response to pharmacological treatment. However, those with CMT reported greater antidepressant side effect burden.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Beyond abstinence and relapse II: momentary relationships between stress, craving, and lapse within clusters of patients with similar patterns of drug use

RATIONALE

Given that many patients being treated for opioid-use disorder continue to use drugs, identifying clusters of patients who share similar patterns of use might provide insight into the disorder, the processes that affect it, and ways that treatment can be personalized.

OBJECTIVES AND METHODS

We applied hierarchical clustering to identify patterns of opioid and cocaine use in 309 participants being treated with methadone or buprenorphine (in a buprenorphine-naloxone formulation) for up to 16 weeks. A smartphone app was used to assess stress and craving at three random times per day over the course of the study.

RESULTS

Five basic patterns of use were identified: frequent opioid use, frequent cocaine use, frequent dual use (opioids and cocaine), sporadic use, and infrequent use. These patterns were differentially associated with medication (methadone vs. buprenorphine), race, age, drug-use history, drug-related problems prior to the study, stress-coping strategies, specific triggers of use events, and levels of cue exposure, craving, and negative mood. Craving tended to increase before use in all except those who used sporadically. Craving was sharply higher during the 90 min following moderate-to-severe stress in those with frequent use, but only moderately higher in those with infrequent or sporadic use.

CONCLUSIONS

People who share similar patterns of drug-use during treatment also tend to share similarities with respect to psychological processes that surround instances of use, such as stress-induced craving. Cluster analysis combined with smartphone-based experience sampling provides an effective strategy for studying how drug use is related to personal and environmental factors.

Feasibility of Delivering a Cognitive Behavioural Therapy-Based Resilience Curriculum to Young Mothers by Public Health Nurses

Background:

Young mothers have higher rates of mental health problems, yet can be difficult to engage in care. Few interventions exist targeting the full range of mental health problems these women face. While transdiagnostic psychotherapies have been utilized in adolescent groups, they have not been tested in young mothers.

Objective:

Our objective was to examine the feasibility and acceptability of a public health nurse-delivered transdiagnostic CBT-based resilience curriculum for young mothers in a supported school setting, and to determine preliminary estimates of the program’s effects.

Methods:

56 mothers, 21 years of age or younger were recruited from a supported high school program in Canada. Using a pretest/post-test design with no control group, measures of maternal depression, anxiety, emotion regulation, and offspring behaviour were collected immediately before and after the completion of the weekly 10-session intervention.

Results:

The intervention was feasible and acceptable to young mothers. While few statistically significant changes were noted in the complete sample, for those with moderate-severe depression at baseline, program participation resulted in clinically meaningful improvements in depression, anxiety, and emotion regulation.

Conclusion:

Provision of a transdiagnostic CBT-based resilience-building program delivered by public health nurses in a supported school setting was both feasible and well-tolerated. Given the preliminary nature of this study, its clinical utility is unclear, though it may have benefits for young mothers with more significant mental health problems at baseline.

Characterization of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder Using Ketamine as an Experimental Medicine Probe

Comorbid posttraumatic stress disorder and major depressive disorder (PTSD + MDD) is the most common pathological response to trauma, yet despite their synergistic detriment to health, knowledge regarding the neurobiological mechanism underlying PTSD + MDD is extremely limited. This study proposes a novel model of PTSD + MDD that is built on biological systems shown to underlay PTSD + MDD and takes advantage of ketamine’s unique suitability to probe PTSD + MDD due to its rescue of stress-related neuroplasticity deficits. The central hypothesis is that changes in PTSD + MDD clinical symptoms are associated with functional connectivity changes and cognitive dysfunction and that ketamine infusions improve clinical symptoms by correction of functional connectivity changes and improvement in cognition. Participants with PTSD + MDD (n = 42) will be randomized to receive a series of six ketamine infusions or saline-placebo over three weeks. Pre/post-measures will include: (1) neuroimaging; (2) cognitive functioning task performance; and (3) PTSD, MDD, and rumination self-report measures. These measures will also be collected once in a trauma-exposed group including PTSD-only (n = 10), trauma-exposed-MDD (TE-MDD; n = 10), and healthy controls (HC, n = 21). Successful completion of the study will strongly support the concept of a biologically-based model of PTSD + MDD. The results will (1) identify functional imaging signatures of the mechanisms underpinning pathological responses to trauma, (2) shift focus from mono-diagnostic silos to unified biological and behavioral disease processes and, thus, (3) inform interventions to correct dysregulation of PTSD + MDD symptom clusters thereby supporting more precise treatments and better outcomes.

Effects of bright light therapy for depression during pregnancy: a randomised, double-blind controlled trial

OBJECTIVES

Approximately 11%-13% of pregnant women suffer from depression. Bright light therapy (BLT) is a promising treatment, combining direct availability, sufficient efficacy, low costs and high safety for both mother and child. Here, we examined the effects of BLT on depression during pregnancy.

DESIGN

Randomised, double-blind controlled trial.

SETTING

Primary and secondary care in The Netherlands, from November 2016 to March 2019.

PARTICIPANTS

67 pregnant women (12-32 weeks gestational age) with a DSM-5 diagnosis of depressive disorder (Diagnostic and Statistical Manual of Mental Disorders).

INTERVENTIONS

Participants were randomly allocated to treatment with either BLT (9000 lux, 5000 K) or dim red light therapy (DRLT, 100 lux, 2700 K), which is considered placebo. For 6 weeks, both groups were treated daily at home for 30 min on awakening. Follow-up took place weekly during the intervention, after 6 weeks of therapy, 3 and 10 weeks after treatment and 2 months postpartum.

PRIMARY AND SECONDARY OUTCOME MEASURES

Depressive symptoms were measured primarily with the Structured Interview Guide for the Hamilton Depression Scale-Seasonal Affective Disorder. Secondary measures were the Hamilton Rating Scale for Depression and the Edinburgh Postnatal Depression Scale. Changes in rating scale scores of these questionnaires over time were analysed using generalised linear mixed models.

RESULTS

Median depression scores decreased by 40.6%-53.1% in the BLT group and by 50.9%-66.7% in the DRLT group. We found no statistically significant difference in symptom change scores between BLT and DRLT. Sensitivity and post-hoc analyses did not change our findings.

CONCLUSIONS

Depressive symptoms of pregnant women with depression improved in both treatment arms. More research is necessary to determine whether these responses represent true treatment effects, non-specific treatment responses, placebo effects or a combination hereof.

TRIAL REGISTRATION NUMBER

NTR5476.

Prognosis and Improved Outcomes in Major Depression: A Review

(Reprinted from Transl Psychiatry. 2019 Apr 3; 9(1):127. Open access; is licensed under a Creative Commons Attribution 4.0 International License).

Personalized Psychiatry and Depression: The Role of Sociodemographic and Clinical Variables

Despite several pharmacological options, the clinical outcomes of major depressive disorder (MDD) are often unsatisfactory. Personalized psychiatry attempts to tailor therapeutic interventions according to each patient's unique profile and characteristics. This approach can be a crucial strategy in improving pharmacological outcomes in MDD and overcoming trial-and-error treatment choices. In this narrative review, we evaluate whether sociodemographic (i.e., gender, age, race/ethnicity, and socioeconomic status) and clinical [i.e., body mass index (BMI), severity of depressive symptoms, and symptom profiles] variables that are easily assessable in clinical practice may help clinicians to optimize the selection of antidepressant treatment for each patient with MDD at the early stages of the disorder. We found that several variables were associated with poorer outcomes for all antidepressants. However, only preliminary associations were found between some clinical variables (i.e., BMI, anhedonia, and MDD with melancholic/atypical features) and possible benefits with some specific antidepressants. Finally, in clinical practice, the assessment of sociodemographic and clinical variables considered in our review can be valuable for early identification of depressed individuals at high risk for poor responses to antidepressants, but there are not enough data on which to ground any reliable selection of specific antidepressant class or compounds. Recent advances in computational resources, such as machine learning techniques, which are able to integrate multiple potential predictors, such as individual/ clinical variables, biomarkers, and genetic factors, may offer future reliable tools to guide personalized antidepressant choice for each patient with MDD.

Depression Outcome Expectancy in Primary Care in Singapore: Symptom Severity as a Mediating Determinant

BACKGROUND

Depression has been identified as the most common mental illness in Singapore. To address this growing concern, the current study focused on the population within the primary care setting since depression has been demonstrated to be highly prevalent in these patients. This study examined the possible predictors of outcome expectancy based on illness perception and depression severity.

METHODS

One hundred and one adult patients with depressive symptoms in primary care were recruited for a cross-sectional study. Positive outcome expectancy was measured using the Depression Change Expectancy Scale, and illness perception was measured using the Illness Perception Questionnaire Mental Health. Depression severity was derived from the Patient Health Questionnaire-9 scores extracted from the participants' medical records. Regression and mediation analyses were applied to explore possible predictors of positive outcome expectancy.

RESULTS

Regression analysis demonstrated that symptom severity, and specific dimensions under illness perception (i.e., perception of chronicity, perception of personal control, and perception of treatment control) were the most significant predictors of positive outcome expectancy. Mediation analysis found that symptom severity partially mediated the relationship between perception of chronicity and positive outcome expectancy.

CONCLUSIONS

Pharmacotherapy, interventions from allied health professionals, and psychotherapeutic interventions (e.g., strategies from positive psychology, solution-focused therapy, and strengths-based cognitive behavioral therapy) that aim to directly alleviate depressive symptoms as well as improve the perceptions of chronicity, personal control, and treatment control could potentially enhance treatment benefits in primary care patients with depression.

The Impact of Objective and Subjective Sleep Parameters on Depressive Symptoms during Pregnancy in Women with a Mental Disorder: An Explorative Study

Poor sleep quality during pregnancy is associated with both antepartum and postpartum depression and adverse birth outcomes. This study evaluated both objective and subjective sleep quality and the effects on the subsequent course of antepartum depressive symptoms in psychiatric patients. This observational explorative study was embedded in an ongoing study focusing on pregnant women with a mental disorder and was performed in 18 patients (24–29 weeks pregnant). Depressive symptoms were assessed throughout pregnancy using the Edinburgh Postnatal Depression Scale (EPDS) with 5-week intervals. Sleep was assessed with actigraphy, the Pittsburgh Sleep Quality Index (PSQI) and sleep diaries at the start of the study. We studied correlations between sleep parameters and EPDS scores cross-sectionally using Spearman correlation. Next, we studied the course of antepartum EPDS scores over time per sleep parameter using generalized linear mixed modelling analysis. Objectively measured fragmentation index, total PSQI score and 4 PSQI subscales (sleep quality, sleep duration, sleep disturbances and daytime dysfunctions) were significantly correlated with EPDS scores when measured cross-sectionally at the start. Six objectively and subjectively measured sleep parameters had moderate to large effects on the course of depressive symptoms through the third trimester, but these effects were not statistically significant. More research is necessary to explore the causality of the direction between sleep problems and antepartum depressive symptoms we found in psychiatric patients.

Prognosis and improved outcomes in major depression: a review

Treatment outcomes for major depressive disorder (MDD) need to be improved. Presently, no clinically relevant tools have been established for stratifying subgroups or predicting outcomes. This literature review sought to investigate factors closely linked to outcome and summarize existing and novel strategies for improvement. The results show that early recognition and treatment are crucial, as duration of untreated depression correlates with worse outcomes. Early improvement is associated with response and remission, while comorbidities prolong course of illness. Potential biomarkers have been explored, including hippocampal volumes, neuronal activity of the anterior cingulate cortex, and levels of brain-derived neurotrophic factor (BDNF) and central and peripheral inflammatory markers (e.g., translocator protein (TSPO), interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor alpha (TNFα)). However, their integration into routine clinical care has not yet been fully elucidated, and more research is needed in this regard. Genetic findings suggest that testing for CYP450 isoenzyme activity may improve treatment outcomes. Strategies such as managing risk factors, improving clinical trial methodology, and designing structured step-by-step treatments are also beneficial. Finally, drawing on existing guidelines, we outline a sequential treatment optimization paradigm for selecting first-, second-, and third-line treatments for acute and chronically ill patients. Well-established treatments such as electroconvulsive therapy (ECT) are clinically relevant for treatment-resistant populations, and novel transcranial stimulation methods such as theta-burst stimulation (TBS) and magnetic seizure therapy (MST) have shown promising results. Novel rapid-acting antidepressants, such as ketamine, may also constitute a paradigm shift in treatment optimization for MDD.

Predicting clinical course in major depressive disorder: The association between DM-TRD score and symptom severity over time in 1115 outpatients

BACKGROUND

The Dutch Measure for Quantification of Treatment Resistance in Depression (DM-TRD) is a promising prediction tool for major depressive disorder (MDD) based on variables associated with treatment outcome. The objective of our study was to examine the association between the DM-TRD and clinical course in a large cohort of MDD outpatients receiving treatment as usual. Furthermore, we examined whether the addition of an item measuring the presence of childhood adversity improved this association.

METHODS

We included 1115 subjects with MDD (according to the DSM-IV) who were naturalistically treated at seven outpatient departments of a secondary mental healthcare center in the Netherlands. Data on subjects who had a diagnostic work-up between June 2014 and June 2016 were analyzed. Multilevel analyses were performed to examine the association between the DM-TRD score at baseline and clinical course, defined by symptom severity according to scores on the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) over time. We also investigated whether an extra item measuring childhood adversity improved the model.

RESULTS

The model including the DM-TRD and its interaction with time was superior to previous models. The addition of childhood adversity and its interaction with time did not improve the model.

CONCLUSIONS

In depressed outpatients receiving treatment as usual, the solid longer-term association between higher DM-TRD scores and worse clinical course supports its usefulness in clinical practice. Childhood adversity did not improve the model value indicating that-counterintuitively-this parameter offers no additional predictive power to the variables included.

Anxiety during ketamine infusions is associated with negative treatment responses in major depressive disorder

About 20 to 30 percent of patients with Major Depressive Disorder (MDD) do not respond to standard treatment and are considered treatment-resistant. The N-methyl-d-aspartate (NMDA) glutamate receptor antagonist ketamine has demonstrated rapid antidepressant effects in treatment-resistant MDD, but it is unknown whether its acute psychological effects are related to the later antidepressant effect. Therefore, we investigated the association between antidepressant responses to ketamine and the quality of ketamine-induced psychological experiences in MDD. A total of 31 patients (M = 49.5 ± 11.2 years, 16 women) were treated with three ketamine infusions per week (0.5 mg/ kg over 40 min) administered for two consecutive weeks. Depression severity was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) at baseline, after four and 24 h and at end of treatment. The 5-Dimensional Altered States of Consciousness Rating Scale (5D-ASC) was applied four hours after the first infusion to assess the subjective quality of acute psychological effects. Patients with a ≥ 50% MADRS reduction from baseline to end of treatment were considered as responders. After six infusions, 17 of 31 patients (55%) showed a response to ketamine treatment, while 14 patients (45%) had no response. Anxiety-related experiences induced by ketamine were significantly higher in non-responders. Percentage MADRS reduction after four hours and individual levels of ketamine-induced anxiety were predictive of a response at end of treatment. The study demonstrated the considerable impact of ketamine-induced anxiety on the antidepressant efficacy of ketamine. It underpins the importance of considering patients' subjective experiences and underlines the possibility of a phenotypic response predictor.

Can targeted metabolomics predict depression recovery? Results from the CO-MED trial

Metabolomics is a developing and promising tool for exploring molecular pathways underlying symptoms of depression and predicting depression recovery. The AbsoluteIDQ™ p180 kit was used to investigate whether plasma metabolites (sphingomyelins, lysophosphatidylcholines, phosphatidylcholines, and acylcarnitines) from a subset of participants in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial could act as predictors or biologic correlates of depression recovery. Participants in this trial were assigned to one of three pharmacological treatment arms: escitalopram monotherapy, bupropion-escitalopram combination, or venlafaxine-mirtazapine combination. Plasma was collected at baseline in 159 participants and again 12 weeks later at study exit in 83 of these participants. Metabolite concentrations were measured and combined with clinical and sociodemographic variables using the hierarchical lasso to simultaneously model whether specific metabolites are particularly informative of depressive recovery. Increased baseline concentrations of phosphatidylcholine C38:1 showed poorer outcome based on change in the Quick Inventory of Depressive Symptoms (QIDS). In contrast, an increased ratio of hydroxylated sphingomyelins relative to non-hydroxylated sphingomyelins at baseline and a change from baseline to exit suggested a better reduction of symptoms as measured by QIDS score. All metabolite-based models performed superior to models only using clinical and sociodemographic variables, suggesting that metabolomics may be a valuable tool for predicting antidepressant outcomes.

Predictors of Response and Remission to Antidepressants in Geriatric Depression: A Systematic Review

BACKGROUND

Geriatric depression is a heterogeneous disorder that increases morbidity and mortality in a population that is already vulnerable. Predicting response and remission to antidepressants could help clinicians to optimize the management of antidepressants and reduce the consequences of depression.

METHOD

The aim of this article is to present results of a systematic review of the literature on predictive factors related to antidepressant response and remission in older adults with depression.

MAIN FINDINGS

We identified sociodemographic, clinical, neuropsychological, neuroimaging, and genetic factors that could be potential predictors of outcomes. Inconsistent findings and methodological differences among studies, however, limit the generalizability and application of these predictors in clinical practice. The results of our review confirm that geriatric depression includes many subgroups of patients with particular endophenotypes that may influence the course of depression.

CONCLUSION

Further studies are needed to characterize depression subgroups in order to better understand the pathophysiology of late life depression and to find specific predictors for each group of patients.

Do baseline sub-threshold hypomanic symptoms affect acute-phase antidepressant outcome in outpatients with major depressive disorder? Preliminary findings from the randomized CO-MED trial

Sub-threshold hypomanic symptoms are common in major depressive disorder. This study evaluated the prevalence, the clinical and sociodemographic correlates, and the overall and differential effects of the presence/absence of sub-threshold hypomanic symptoms at baseline on acute-phase treatment outcomes with bupropion-plus-escitalopram combination, escitalopram monotherapy, and venlafaxine-plus-mirtazapine combination. Combining medications to enhance depression outcomes (CO-MED) trial participants (n = 665) were designated as sub-threshold hypomanic symptoms present (Altman Self-Rating Mania Scale score (ASRM) ≥ 1) or absent (ASRM = 0) and compared on clinical and sociodemographic features and remission rates. Participants with sub-threshold hypomanic symptoms (n = 335/665, 50.4%) were more likely to be black and non-Hispanic, have comorbid medical and psychiatric disorders, experience longer index episodes, and report lower depression severity and psychosocial impairment. Intent-to-treat remission rates were lower overall (absent = 42.7%, present = 34.0%, p = 0.02), with escitalopram monotherapy (absent = 45.8%, present = 31.6%, p = 0.03), and with venlafaxine-XR-plus-mirtazapine combination (absent = 44.4%, present = 30.1%, p = 0.03) but not with bupropion-plus-escitalopram combination (absent = 37.7%, present = 40.0%, p = 0.73). Participants without sub-threshold hypomanic symptoms were more likely to remit than those with such symptoms overall [odds ratio (OR) = 1.49], with escitalopram monotherapy (OR = 1.71), and with venlafaxine-plus-mirtazapine combination (OR = 1.97) but not with bupropion-plus-escitalopram combination (OR = 0.96), even after controlling for baseline depression severity, psychosocial impairment, and number of comorbid psychiatric disorders. Sub-threshold hypomanic symptoms (found in about 50% of patients in this report) were associated with lower remission rates with escitalopram monotherapy and with venlafaxine-plus-mirtazapine combination but not with the bupropion-plus-escitalopram combination.

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

Validating pre-treatment body mass index as moderator of antidepressant treatment outcomes: Findings from CO-MED trial

BACKGROUND

Currently, there are no valid clinical or biological markers to personalize the treatment of depression. Recent evidence suggests that body mass index (BMI) may guide the selection of antidepressant medications with different mechanisms of action.

METHODS

Combining Medications to Enhance Depression Outcomes (CO-MED) trial participants with BMI measurement (n = 662) were categorized as normal- or underweight (<25), overweight (25-<30), obese I (30-<35), and obese II+ (≥35). Logistic regression analysis with remission as the dependent variable and treatment arm-by-BMI category interaction as the primary independent variable was used to evaluate if BMI differentially predicted response to escitalopram (SSRI) monotherapy, bupropion-escitalopram combination, or venlafaxine-mirtazapine combination, after controlling for gender and baseline depression severity.

RESULTS

Remission rates among the three treatment arms differed on the basis of pre-treatment BMI (chi-square=12.80, degrees of freedom=6, p = .046). Normal- or under-weight participants were less likely to remit with the bupropion-SSRI combination (26.8%) than SSRI monotherapy (37.3%, number needed to treat or NNT = 9.5) or venlafaxine-mirtazapine combination (44.4%, NNT = 5.7). Conversely, obese II+ participants were more likely to remit with bupropion-SSRI (47.4%) than SSRI monotherapy (28.6%, NNT = 5.3) or venlafaxine-mirtazapine combination (37.7%, NNT = 10.3). Remission rates did not differ among overweight and obese I participants.

LIMITATIONS

Secondary analysis, higher rates of obesity than the general population.

CONCLUSIONS

Antidepressant selection in clinical practice can be personalized with BMI measurements. Bupropion-SSRI combination should be avoided in normal- or under-weight depressed outpatients as compared to SSRI monotherapy and venlafaxine-mirtazapine combination and preferred in those with BMI≥35.

Peripheral biomarkers of major depression and antidepressant treatment response: Current knowledge and future outlooks

BACKGROUND

In recent years, we have accomplished a deeper understanding about the pathophysiology of major depressive disorder (MDD). Nevertheless, this improved comprehension has not translated to improved treatment outcome, as identification of specific biologic markers of disease may still be crucial to facilitate a more rapid, successful treatment. Ongoing research explores the importance of screening biomarkers using neuroimaging, neurophysiology, genomics, proteomics, and metabolomics measures.

RESULTS

In the present review, we highlight the biomarkers that are differentially expressed in MDD and treatment response and place a particular emphasis on the most recent progress in advancing technology which will continue the search for blood-based biomarkers.

LIMITATIONS

Due to space constraints, we are unable to detail all biomarker platforms, such as neurophysiological and neuroimaging markers, although their contributions are certainly applicable to a biomarker review and valuable to the field.

CONCLUSIONS

Although the search for reliable biomarkers of depression and/or treatment outcome is ongoing, the rapidly-expanding field of research along with promising new technologies may provide the foundation for identifying key factors which will ultimately help direct patients toward a quicker and more effective treatment for MDD.

Personalized Antidepressant Selection and Pathway to Novel Treatments: Clinical Utility of Targeting Inflammation

Major depressive disorder (MDD) is a chronic condition that affects one in six adults in the US during their lifetime. The current practice of antidepressant medication prescription is a trial-and-error process. Additionally, over a third of patients with MDD fail to respond to two or more antidepressant treatments. There are no valid clinical markers to personalize currently available antidepressant medications, all of which have similar mechanisms targeting monoamine neurotransmission. The goal of this review is to summarize the recent findings of immune dysfunction in patients with MDD, the utility of inflammatory markers to personalize treatment selection, and the potential of targeting inflammation to develop novel antidepressant treatments. To personalize antidepressant prescription, a c-reactive protein (CRP)-matched treatment assignment can be rapidly implemented in clinical practice with point-of-care fingerstick tests. With this approach, 4.5 patients need to be treated for 1 additional remission as compared to a CRP-mismatched treatment assignment. Anti-cytokine treatments may be effective as novel antidepressants. Monoclonal antibodies against proinflammatory cytokines, such as interleukin 6, interleukin 17, and tumor necrosis factor α, have demonstrated antidepressant effects in patients with chronic inflammatory conditions who report significant depressive symptoms. Additional novel antidepressant strategies targeting inflammation include pharmaceutical agents that block the effect of systemic inflammation on the central nervous system. In conclusion, inflammatory markers offer the potential not only to personalize antidepressant prescription but also to guide the development of novel mechanistically-guided antidepressant treatments.

Pharmacogenomics and Biomarkers of Depression

The standard of care for antidepressant treatment in major depressive disorder (MDD) is a trial-and-error approach. Patients often have to undergo multiple medication trials for weeks to months before finding an effective treatment. Clinical factors such as severity of baseline symptoms and the presence of specific individual (anhedonia or insomnia) or cluster (atypical, melancholic, or anxious) of symptoms are commonly used without any evidence of their utility in selecting among currently available antidepressants. Genomic and proteomic biomarker have gained recent attention for their potential in informing antidepressant medication selection. In this report, we have reviewed some of the major pharmacogenomics studies along with individual genetic and proteomic biomarker of antidepressant response. Additionally, we have reviewed the blood-based protein biomarkers that can inform selection of one antidepressant over another. Among all currently available biomarkers, C-reactive protein (CRP) appears to be the most promising and pragmatic choice. Low CRP (<1 mg/L) in patients with MDD predicts better response to escitalopram while higher levels are associated with better response to noradrenergic/dopaminergic antidepressants. Future studies are needed to demonstrate the superiority of a CRP-based treatment assignment over high-quality measurement-based care in real-world clinical practices.

Worsening Anxiety, Irritability, Insomnia, or Panic Predicts Poorer Antidepressant Treatment Outcomes: Clinical Utility and Validation of the Concise Associated Symptom Tracking (CAST) Scale

BACKGROUND

We report on the psychometric properties of the 16-item Concise Associated Symptom Tracking Scale self-report scale and its clinical utility.

METHODS

The 5-domain (irritability, anxiety, mania, insomnia, and panic) structure of Concise Associated Symptom Tracking Scale was validated with confirmatory factor analysis in Combining Medications to Enhance Depression Outcomes trial participants at baseline (n=664). Correlations with other clinical measures were used for convergent and divergent validity. In participants with at least one postbaseline visit (n=630), worsening in each Concise Associated Symptom Tracking Scale domain was defined as ≥1.28 SD increase from baseline for each visit (weeks 1, 2, 4, and 6) only. Worsening in any domain (except mania) was defined as overall worsening. Association of domain-specific and overall worsening with remission was tested with logistic regression analyses.

RESULTS

The 5-domain structure had adequate model fit on confirmatory factor analysis (GFI=0.93, CFI=0.89, and RMSEA=0.07). Scores on anxiety, panic, insomnia, and mania significantly correlated with Hamilton Rating Scale for Depression anxiety subscale (rs=0.27), Psychiatric Diagnostic Screening Questionnaire-panic scale (rs=0.35), sum of 3 Quick Inventory of Depressive Symptomatology Self-Report insomnia items (rs=0.55), and Altman Self-Rating Mania scale (rs=0.41), respectively. From baseline to week 6, 5.2%, 7.5%, 47.6%, 15.6%, 6.2%, and 27.6% participants (n=630) experienced irritability, anxiety, mania, insomnia, panic, and overall worsening, respectively. Participants with overall worsening were less likely to remit (31.6%) than those without any worsening (43.9%; odds ratio=0.53, 95% CI=0.36, 0.78).

CONCLUSION

The 16-item Concise Associated Symptom Tracking Scale self-report has acceptable psychometric properties. Clinically significant worsening of irritability, anxiety, insomnia, or panic with antidepressant treatment is associated with poorer outcomes.

Early improvement as a resilience signal predicting later remission to antidepressant treatment in patients with Major Depressive Disorder: Systematic review and meta-analysis

Early improvement of depressive symptoms during the first two weeks of antidepressant treatment has been discussed to be a resilience signal predicting a later positive treatment outcome in patients with Major Depressive Disorder (MDD). However, the predictive value of early improvement varies between studies, and the use of different antidepressants may explain heterogeneous results. The objective of this review was to assess the predictive value of early improvement on later response and remission and to identify antidepressants with the highest chance of early improvement. We included 17 randomized controlled trials investigating early improvement in 14,779 adult patients with MDD comparing monotherapy with an antidepressant against placebo or another antidepressant drug. 62% (range: 35-85%) of patients treated with an antidepressant and 47% (range: 21-69%) with placebo were early improver, defined as a >20%/25% symptom reduction after two weeks of treatment. Early improvement predicted response and remission after 5-12 weeks of treatment with high sensitivity (85%; 95%-CI: 84.3 to 85.7) and low to moderate specificity (54%; 95%-CI: 53.1 to 54.9). Early improver had a 8.37 fold (6.97-10.05) higher likelihood to become responder and a 6.38 fold (5.07-8.02) higher likelihood to be remitter at endpoint than non-improver. The highest early improver rates were achieved in patients treated with mirtazapine or a tricyclic antidepressant. This finding of a high predictive value of early improvement on treatment outcome may be important for treatment decisions in the early course of antidepressant treatment. Further studies should test the efficacy of such early treatment decisions.

A combined marker of early non-improvement and the occurrence of melancholic features improve the treatment prediction in patients with Major Depressive Disorders

BACKGROUND

Early Improvement of depressive symptoms within two weeks of antidepressant treatment is a highly sensitive but less specific predictor of later treatment outcome. The aim of this study was to identify clinical features at treatment initiation which are associated with early improvement and non-improvement as well as to identify variables predicting non-remission in patients showing an early improvement.

METHODS

889 patients with a major depressive episode according to DSM-IV who had participated in an antidepressant treatment trial served as study sample. Clinical predictors (demographic variables, psychopathology, comorbid disorders) were analysed in 698 (79%) early improver (Hamilton Depression Rating Scale reduction > 20% after 14 days of treatment) compared to 191 (21%) non-improver. Furthermore, clinical predictors for later remission and non-remission were analysed in the 698 patients showing an early improvement.

RESULTS

Patients with more severe depression and suicidality were more likely to become non-improver, and also non-remitter after 8 weeks of treatment in case of early improvement. Early improver with melancholic, anxious or atypical depression as well as with comorbid social phobia or avoidant personality disorder had an increased risk for non-remission at study end. The combined marker of early non-improvement and the occurrence of melancholic features increased the specificity of treatment prediction from 30% to 90%.

LIMITATIONS

Comorbid disorders were only assessed at baseline.

CONCLUSIONS

Patients with early non-improvement and melancholic features at treatment initiation have a particularly high risk of later non-remission. This group of patients should be considered more attention in treatment decisions.

Depression as a moderator of STAIR Narrative Therapy for women with post-traumatic stress disorder related to childhood abuse

Background: Depression among those who have experienced childhood abuse is associated with earlier onset, more persistent and severe symptoms, more frequent relapse, and poorer treatment outcomes across a variety of psychiatric disorders. In addition, individuals with a history of childhood abuse are more likely to develop post-traumatic stress disorder (PTSD) co-occurring with depression. Objective: This study evaluated whether severity of depression moderated the outcome in a PTSD treatment for childhood abuse survivors. Specifically, we assessed whether individuals with significant depression obtained better outcomes when provided with a two-module treatment which included a skills training component with behavioral activation interventions, Skills Training in Affective and Interpersonal Regulation (STAIR) followed by a trauma-focused component, Narrative Therapy, as compared to two control conditions where one component (STAIR or Narrative Therapy) was replaced with Supportive Counseling. Method: Participants were 104 women with PTSD related to childhood abuse. Participants were randomized into three conditions: (1) STAIR plus Narrative Therapy (SNT), (2) STAIR plus Supportive Counseling (SSC), and (3) Supportive Counseling plus Narrative Therapy (SCNT). Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) PTSD symptom severity was assessed at pre-treatment, post-treatment, and 3 and 6 month follow-up. Results: Participants with severe depression showed superior PTSD symptom reduction following SNT, while those in the other two conditions experienced a loss of improvement after treatment ended. A similar finding was obtained among those with moderate depression, while among those with low levels of depression, outcomes did not differ across the three treatment conditions. Conclusions: Childhood abuse survivors with severe depression obtained superior outcomes in a treatment that combined skills training with trauma-focused work. Skills packages which contain behavioral activation interventions in combination with trauma-focused work may be particularly beneficial for patients with childhood abuse and severe depression.

Untreated duration predicted the severity of depression at the two-year follow-up point

Background

No study has investigated the impact of the duration of untreated depression (DUD) on the severity of depression at the two-year follow-up point in patients with major depressive disorder (MDD) who discontinued pharmacotherapy. This study aimed to investigate this issue.

Methods

This study enrolled 155 subjects with MDD at baseline, and 101 subjects who had discontinued pharmacotherapy for 17.1 ± 5.8 months were assessed at the two-year follow-up point. DUD was defined as the interval between the onset of the index major depressive episode and the start of pharmacotherapy. The 17-item Hamilton Depression Rating Scale (HAMD) was used to evaluate depression. Multiple linear regressions were used to examine the impacts of DUD on the severity and improvement percentage (IP) of depression at follow-up.

Results

A longer DUD was significantly associated with a greater severity and a lower IP of depression at follow-up. After controlling for confounding factors, DUD was the most significant factor predicting the severity and IP of depression at follow-up. DUD was more strongly associated with the prognosis of depression at follow-up than depression and anxiety severities at baseline.

Conclusions

The DUD at baseline independently predicted the severity of depression at the two-year follow-up point. Although the patients had discontinued pharmacotherapy for nearly 1.5 years, the impact of the DUD on the severity of depression persisted at follow-up. The DUD was an important index that predicted the severity of depression at the two-year follow-up point.

Efficacy of Desvenlafaxine Compared With Placebo in Major Depressive Disorder Patients by Age Group and Severity of Depression at Baseline

PURPOSE

This post hoc meta-analysis evaluated the efficacy and safety of desvenlafaxine 50 and 100 mg versus placebo across age groups and severity of depression at baseline in patients with major depressive disorder.

METHODS

Data from placebo and desvenlafaxine 50-mg and 100-mg dose arms were pooled from 9 short-term, placebo-controlled, major depressive disorder studies (N = 4279). Effects of age (18-40 years, >40 to <55 years, 55-<65 years, and ≥65 years) and baseline depression severity (mild, 17-item Hamilton Rating Scale for Depression total score [HAM-D17] ≤18; moderate, HAM-D17 >18 to <25; severe, HAM-D17 ≥25) on desvenlafaxine efficacy were assessed using analysis of covariance for continuous end points and logistic regression for categorical end points.

FINDINGS

Desvenlafaxine-treated (50 or 100 mg/d) patients had significantly (P < 0.05, 2-sided) greater improvement in most measures of depression and function compared with placebo for patients 18 to 40 years, older than 40 to younger than 55 years, and 55 to younger than 65 years, with no significant evidence of an effect of age. Desvenlafaxine significantly improved most measures of depression and function in moderately and severely depressed patients. There was a significant baseline severity by treatment interaction for HAM-D17 total score only (P = 0.027), with a larger treatment effect for the severely depressed group.

IMPLICATIONS

Desvenlafaxine significantly improved depressive symptoms in patients younger than 65 years and in patients with moderate or severe baseline depression. Sample sizes were not adequate to assess desvenlafaxine efficacy in patients 65 years or older or with mild baseline depression.

SUICIDAL DEPRESSED PATIENTS RESPOND LESS WELL TO ANTIDEPRESSANTS IN THE SHORT TERM

BACKGROUND

Suicidal thoughts and behaviors could be associated to a poor response to antidepressant treatment, but the exclusion of suicidal patients from randomized clinical trials restricts the available knowledge. In this study, we aimed at defining more precisely the response to antidepressants among suicidal patients and the threshold of suicidality that best predicts a poor response.

METHOD

We investigated the short-term response to a new antidepressant treatment of 4,041 depressed outpatients depending on their suicidal status (passive or active suicidal ideation (SI), history of suicide attempts [SAs]), either self-rated or clinician-rated. Depression outcomes, measured with the Hospital Anxiety and Depression Scale, and remission rates were compared depending on suicidal status at baseline using logistic regression models.

RESULTS

Using either a qualitative or a quantitative approach to measure SI, we found that suicidal patients were less likely to improve or attain remission, but not more likely to worsen, than nonsuicidal patients. In the multivariate analyses, SI (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.18-1.65) and a history of SA (OR = 1.39; 95% CI: 1.16-1.66) were the best predictors of nonremission, independently of the class of antidepressant treatment.

CONCLUSION

Antidepressant treatment seems to be less effective among those patients that need it most. Clinical trials including suicidal patients are needed to investigate specific treatment options.

Clinical correlates of difficult-to-treat depression: Exploring an integrated day-care model of treatment

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.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Analysis of potentially predictive factors of efficacy of adjunct extended-release quetiapine fumarate in patients with major depressive disorder

Identification of predictors of treatment response in patients with major depressive disorder (MDD) may facilitate improved disease management. Data were pooled from two 6-week, double-blind, placebo-controlled studies of extended-release quetiapine (quetiapine XR; 150 or 300 mg/day) as adjunct to ongoing antidepressant therapy. Effects of psychiatric history and baseline demographic and disease characteristics on efficacy outcomes (Week 6 Montgomery Åsberg Depression Rating Scale [MADRS] total score reduction) were evaluated in population subgroups (quetiapine XR both doses pooled, n = 616; placebo, n = 303). Baseline Clinical Global Impressions-Severity (CGI-S) score and previous depressive episodes on Week 6 MADRS total score change, and baseline MADRS individual item scores on Week 6 change in CGI-Improvement score, were also evaluated. No major differences between responders and non-responders to quetiapine XR were observed for patient characteristics or demographic and disease characteristics. No suggestion of a predictive association was found between baseline CGI-S score, number of depressive episodes, and baseline MADRS item scores and efficacy outcomes. These analyses showed no major differences between responders and non-responders, and no predictive association between the parameters assessed and efficacy outcomes for adjunct quetiapine XR in patients with MDD and an inadequate response to prior antidepressant therapy.