The speech analysis approach to determining onset of improvement under antidepressants

Development and validation of a machine learning-based vocal predictive model for major depressive disorder

BACKGROUND

Variations in speech intonation are known to be associated with changes in mental state over time. Behavioral vocal analysis is an algorithmic method of determining individuals' behavioral and emotional characteristics from their vocal patterns. It can provide biomarkers for use in psychiatric assessment and monitoring, especially when remote assessment is needed, such as in the COVID-19 pandemic. The objective of this study was to design and validate an effective prototype of automatic speech analysis based on algorithms for classifying the speech features related to MDD using a remote assessment system combining a mobile app for speech recording and central cloud processing for the prosodic vocal patterns.

METHODS

Machine learning compared the vocal patterns of 40 patients diagnosed with MDD to the patterns of 104 non-clinical participants. The vocal patterns of 40 patients in the acute phase were also compared to 14 of these patients in the remission phase of MDD.

RESULTS

A vocal depression predictive model was successfully generated. The vocal depression scores of MDD patients were significantly higher than the scores of the non-patient participants (p < 0.0001). The vocal depression scores of the MDD patients in the acute phase were significantly higher than in remission (p < 0.02).

LIMITATIONS

The main limitation of this study is its relatively small sample size, since machine learning validity improves with big data.

CONCLUSIONS

The computerized analysis of prosodic changes may be used to generate biomarkers for the early detection of MDD, remote monitoring, and the evaluation of responses to treatment.

Investigating temporal and prosodic markers in clinical high-risk for psychosis participants using automated acoustic analysis

AIM

Language disturbances are a candidate biomarker for the early detection of psychosis. Temporal and prosodic abnormalities have been observed in schizophrenia patients, while there is conflicting evidence whether such deficits are present in participants meeting clinical high-risk for psychosis (CHR-P) criteria.

METHODS

Clinical interviews from CHR-P participants (n = 50) were examined for temporal and prosodic metrics and compared against a group of healthy controls (n = 17) and participants with affective disorders and substance abuse (n = 23).

RESULTS

There were no deficits in acoustic variables in the CHR-P group, while participants with affective disorders/substance abuse were characterized by slower speech rate, longer pauses and higher unvoiced frames percentage.

CONCLUSION

Our finding suggests that temporal and prosodic aspects of speech are not impaired in early-stage psychosis. Further studies are required to clarify whether such abnormalities are present in sub-groups of CHR-P participants with elevated psychosis-risk.

Depressive symptoms are specifically related to speech pauses in schizophrenia spectrum disorders

Depression is a common and debilitating mental illness associated with sadness and negativity and is often comorbid with other psychiatric conditions, such as schizophrenia. Depressive symptoms are presently primarily assessed through clinical interviews, however there are other behavioural indicators being investigated as more objective methods of depressive symptom assessment. The present study aimed to evaluate the utility of assessing depression using quantitative speech parameters by comparing speech between 23 schizophrenia/schizoaffective patients with clinically significant depressive symptoms (DP) 19 schizophrenia/schizoaffective patients without depressive symptoms (NDP) and 22 healthy controls with no psychiatric history (HC). Participant audio recordings were transcribed and analyzed to extract five types of speech variables: utterances, words, speaking rate, formulation errors and pauses. The results indicated that DP patients produced significantly more pauses within utterances, and had more utterances with pauses compared to NDP patients and HCs (p = <.05), who performed similarly to each other. Word, speaking rate and formulation errors variables were not significantly different between the patient groups (p > .05). The findings suggest that depressive symptoms may have a specific relationship to speech pauses, and support the potential future use of speech pause assessments as an alternative and objective depression rating and monitoring tool.

Monitoring the effects of therapeutic interventions in depression through self-assessments

The treatment of major psychiatric disorders is an arduous and thorny path for the patients concerned, characterized by polypharmacy, massive adverse side effects, modest prospects of success, and constantly declining response rates. The more important is the early detection of psychiatric disorders prior to the development of clinically relevant symptoms, so that people can benefit from early interventions. A well-proven approach to monitoring mental health relies on voice analysis. This method has been successfully used with psychiatric patients to 'objectively' document the progress of improvement or the onset of relapse. The studies with psychiatric patients over 2-4 weeks demonstrated that daily voice assessments have a notable therapeutic effect in themselves. Therefore, daily voice assessments appear to be a lowthreshold form of therapeutic means that may be realized through self-assessments. To evaluate performance and reliability of this approach, we have carried out a longitudinal study on 82 university students in 3 different countries with daily assessments over 2 weeks. The sample included 41 males (mean age 24.2±3.83 years) and 41 females (mean age 21.6±2.05 years). Unlike other research in the field, this study was not concerned with the classification of individuals in terms of diagnostic categories. The focus lay on the monitoring aspect and the extent to which the effects of therapeutic interventions or of behavioural changes are visible in the results of self-assessment voice analyses. The test persons showed an over-proportionally good adherence to the daily voice analysis scheme. The accumulated data were of generally high quality: sufficiently high signal levels, a very limited number of movement artifacts, and little to no interfering background noise. The method was sufficiently sensitive to detect: i) habituation effects when test persons became used to the daily procedure; and ii) short-term fluctuations that exceeded prespecified thresholds and reached significance. Results are directly interpretable and provide information about what is going well, what is going less well, and where there is a need for action. The proposed self-assessment approach was found to be well-suited to serve as a health-monitoring tool for subjects with an elevated vulnerability to psychiatric disorders or to stress-induced mental health problems. Daily voice assessments are in fact a low-threshold form of therapeutic means that can be realized through selfassessments, that requires only little effort, can be carried out in the test person's own home, and has the potential to strengthen resilience and to induce positive behavioural changes.

Association between acoustic speech features and non-severe levels of anxiety and depression symptoms across lifespan

BACKGROUND

Several studies have investigated the acoustic effects of diagnosed anxiety and depression. Anxiety and depression are not characteristics of the typical aging process, but minimal or mild symptoms can appear and evolve with age. However, the knowledge about the association between speech and anxiety or depression is scarce for minimal/mild symptoms, typical of healthy aging. As longevity and aging are still a new phenomenon worldwide, posing also several clinical challenges, it is important to improve our understanding of non-severe mood symptoms' impact on acoustic features across lifetime. The purpose of this study was to determine if variations in acoustic measures of voice are associated with non-severe anxiety or depression symptoms in adult population across lifetime.

METHODS

Two different speech tasks (reading vowels in disyllabic words and describing a picture) were produced by 112 individuals aged 35-97. To assess anxiety and depression symptoms, the Hospital Anxiety Depression Scale (HADS) was used. The association between the segmental and suprasegmental acoustic parameters and HADS scores were analyzed using the linear multiple regression technique.

RESULTS

The number of participants with presence of anxiety or depression symptoms is low (>7: 26.8% and 10.7%, respectively) and non-severe (HADS-A: 5.4 ± 2.9 and HADS-D: 4.2 ± 2.7, respectively). Adults with higher anxiety symptoms did not present significant relationships associated with the acoustic parameters studied. Adults with increased depressive symptoms presented higher vowel duration, longer total pause duration and short total speech duration. Finally, age presented a positive and significant effect only for depressive symptoms, showing that older participants tend to have more depressive symptoms.

CONCLUSIONS

Non-severe depression symptoms can be related to some acoustic parameters and age. Depression symptoms can be explained by acoustic parameters even among individuals without severe symptom levels.

Association between suicidal ideation and acoustic parameters of university students' voice and speech: a pilot study

PURPOSE

At a worldwide level, suicide is a public health problem that, despite displaying downward trends in several areas of the world, in many countries these rates have increased. One of the elements that contributes to its prevention is an early and dynamic evaluation. Due to this, the objective is to determine the association between acoustic parameters of voice and speech (F0, F1, F2, F3, dB, and Jitter) and suicidal ideation arousal amongst some university students from the city of Temuco, Chile.

METHODS

Attending to this issue, a cross-sectional design study was conducted through a non-probabilistic sampling of sixty 18- and 19-year-old adolescents from the city of Temuco, that went through an acoustic evaluation of their voice and speech after taking a test to determine suicidal ideation. Afterwards, data were analyzed through IBM SPSS version 23.0 software (IBM SPSS Statistics, Armonk, NY), by means of exploratory, descriptive, and inferential statistics taking the variable's levels of measurements and the types of distributions into account.

RESULTS

The results point out that 30% of the adolescents, from both genders, displayed suicidal ideation. Taking into account the acoustic results of their voice, it is possible to recognize that the fundamental frequency (F0), the formants (F1, F2), and Jitter, are the ones that majorly link to the presence of suicidal ideation, both in women and men (p < .05). The characteristics that describe F3 were only linked to the presence of suicidal ideation in men (p < .05).

CONCLUSIONS

It is concluded that the acoustic parameters of voice and speech differ in adolescents with suicidal behavior, opening the possibility of representing a useful tool in the diagnosis of suicide.

Acoustic differences between healthy and depressed people: a cross-situation study

BACKGROUND

Abnormalities in vocal expression during a depressed episode have frequently been reported in people with depression, but less is known about if these abnormalities only exist in special situations. In addition, the impacts of irrelevant demographic variables on voice were uncontrolled in previous studies. Therefore, this study compares the vocal differences between depressed and healthy people under various situations with irrelevant variables being regarded as covariates.

METHODS

To examine whether the vocal abnormalities in people with depression only exist in special situations, this study compared the vocal differences between healthy people and patients with unipolar depression in 12 situations (speech scenarios). Positive, negative and neutral voice expressions between depressed and healthy people were compared in four tasks. Multiple analysis of covariance (MANCOVA) was used for evaluating the main effects of variable group (depressed vs. healthy) on acoustic features. The significances of acoustic features were evaluated by both statistical significance and magnitude of effect size.

RESULTS

The results of multivariate analysis of covariance showed that significant differences between the two groups were observed in all 12 speech scenarios. Although significant acoustic features were not the same in different scenarios, we found that three acoustic features (loudness, MFCC5 and MFCC7) were consistently different between people with and without depression with large effect magnitude.

CONCLUSIONS

Vocal differences between depressed and healthy people exist in 12 scenarios. Acoustic features including loudness, MFCC5 and MFCC7 have potentials to be indicators for identifying depression via voice analysis. These findings support that depressed people's voices include both situation-specific and cross-situational patterns of acoustic features.

Detecting Depression Using an Ensemble Logistic Regression Model Based on Multiple Speech Features

Early intervention for depression is very important to ease the disease burden, but current diagnostic methods are still limited. This study investigated automatic depressed speech classification in a sample of 170 native Chinese subjects (85 healthy controls and 85 depressed patients). The classification performances of prosodic, spectral, and glottal speech features were analyzed in recognition of depression. We proposed an ensemble logistic regression model for detecting depression (ELRDD) in speech. The logistic regression, which was superior in recognition of depression, was selected as the base classifier. This ensemble model extracted many speech features from different aspects and ensured diversity of the base classifier. ELRDD provided better classification results than the other compared classifiers. A technique for identifying depression based on ELRDD, ELRDD-E, was here suggested and tested. It offered encouraging outcomes, revealing a high accuracy level of 75.00% for females and 81.82% for males, as well as an advantageous sensitivity/specificity ratio of 79.25%/70.59% for females and 78.13%/85.29% for males.

Analysis on speech signal features of manic patients

Given the lack of effective biological markers for early diagnosis of bipolar mania, and the tendency for voice fluctuation during transition between mood states, this study aimed to investigate the speech features of manic patients to identify a potential set of biomarkers for diagnosis of bipolar mania. 30 manic patients and 30 healthy controls were recruited and their corresponding speech features were collected during natural dialogue using the Automatic Voice Collecting System. Bech-Rafaelsdn Mania Rating Scale (BRMS) and Clinical impression rating scale (CGI) were used to assess illness. The speech features were compared between two groups: mood group (mania vs remission) and bipolar group (manic patients vs healthy individuals). We found that the characteristic speech signals differed between mood groups and bipolar groups. The fourth formant (F4) and Linear Prediction Coefficient (LPC) (P < .05) were significantly differed when patients transmitted from manic to remission state. The first formant (F1), the second formant (F2), and LPC (P < .05) also played key roles in distinguishing between patients and healthy individuals. In addition, there was a significantly correlation between LPC and BRMS, indicating that LPC may play an important role in diagnosis of bipolar mania. In this study we traced speech features of bipolar mania during natural dialogue (conversation), which is an accessible approach in clinic practice. Such specific indicators may respectively serve as promising biomarkers for benefiting the diagnosis and clinical therapeutic evaluation of bipolar mania.

The effects of acute tryptophan depletion on speech and behavioural mimicry in individuals at familial risk for depression

Major depressive disorder (MDD) has been associated with abnormalities in speech and behavioural mimicry. These abnormalities may contribute to the impairments in interpersonal functioning that are often seen in MDD patients. MDD has also been associated with disturbances in the brain serotonin system, but the extent to which serotonin regulates speech and behavioural mimicry remains unclear. In a randomized, double-blind, crossover study, we induced acute tryptophan depletion (ATD) in individuals with or without a family history of MDD. Five hours afterwards, participants engaged in two behavioural-mimicry experiments in which speech and behaviour were recorded. ATD reduced the time participants waited before speaking, which might indicate increased impulsivity. However, ATD did not significantly alter speech otherwise, nor did it affect mimicry. This suggests that a brief lowering of brain serotonin has limited effects on verbal and non-verbal social behaviour. The null findings may be due to low test sensitivity, but they otherwise suggest that low serotonin has little effect on social interaction quality in never-depressed individuals. It remains possible that recovered MDD patients are more strongly affected.

Assessing Chronic Stress, Coping Skills, and Mood Disorders through Speech Analysis: A Self-Assessment 'Voice App' for Laptops, Tablets, and Smartphones

BACKGROUND

Computerized speech analysis (CSA) is a powerful method that allows one to assess stress-induced mood disturbances and affective disorders through repeated measurements of speaking behavior and voice sound characteristics. Over the past decades CSA has been successfully used in the clinical context to monitor the transition from 'affectively disturbed' to 'normal' among psychiatric patients under treatment. This project, by contrast, aimed to extend the CSA method in such a way that the transition from 'normal' to 'affected' can be detected among subjects of the general population through 10-20 self-assessments.

METHODS

Central to the project was a normative speech study of 5 major languages (English, French, German, Italian, and Spanish). Each language comprised 120 subjects stratified according to gender, age, and education with repeated assessments at 14-day intervals (total n = 697). In a first step, we developed a multivariate model to assess affective state and stress-induced bodily reactions through speaking behavior and voice sound characteristics. Secondly, we determined language-, gender-, and age-specific thresholds that draw a line between 'natural fluctuations' and 'significant changes'. Thirdly, we implemented the model along with the underlying methods and normative data in a self-assessment 'voice app' for laptops, tablets, and smartphones. Finally, a longitudinal self-assessment study of 36 subjects was carried out over 14 days to test the performance of the CSA method in home environments.

RESULTS

The data showed that speaking behavior and voice sound characteristics can be quantified in a reproducible and language-independent way. Gender and age explained 15-35% of the observed variance, whereas the educational level had a relatively small effect in the range of 1-3%. The self-assessment 'voice app' was realized in modular form so that additional languages can simply be 'plugged in' once the respective normative data become available. Results of the longitudinal self-assessment study in home environments demonstrated that CSA methods work well under most circumstances.

CONCLUSIONS

We have successfully developed and tested a self-assessment CSA method that can monitor transitions from 'normal' to 'affected' in subjects of the general population in the broader context of mood disorders. Our easy-to-use 'voice app' evaluates sequences of 10-20 repeated assessments and watches for affect- and stress-induced deviations from baseline that exceed language-, gender-, and age-specific thresholds. Specifically, the 'voice app' provides users with stress-related 'biofeedback' and can help to identify that 10-15% subgroup of the general population that exhibits insufficient coping skills under chronic stress and may benefit from early detection and intervention prior to developing clinically relevant symptoms.

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.

Affective state and voice: cross-cultural assessment of speaking behavior and voice sound characteristics--a normative multicenter study of 577 + 36 healthy subjects

BACKGROUND

Human speech is greatly influenced by the speakers' affective state, such as sadness, happiness, grief, guilt, fear, anger, aggression, faintheartedness, shame, sexual arousal, love, amongst others. Attentive listeners discover a lot about the affective state of their dialog partners with no great effort, and without having to talk about it explicitly during a conversation or on the phone. On the other hand, speech dysfunctions, such as slow, delayed or monotonous speech, are prominent features of affective disorders.

METHODS

This project was comprised of four studies with healthy volunteers from Bristol (English: n = 117), Lausanne (French: n = 128), Zurich (German: n = 208), and Valencia (Spanish: n = 124). All samples were stratified according to gender, age, and education. The specific study design with different types of spoken text along with repeated assessments at 14-day intervals allowed us to estimate the 'natural' variation of speech parameters over time, and to analyze the sensitivity of speech parameters with respect to form and content of spoken text. Additionally, our project included a longitudinal self-assessment study with university students from Zurich (n = 18) and unemployed adults from Valencia (n = 18) in order to test the feasibility of the speech analysis method in home environments.

RESULTS

The normative data showed that speaking behavior and voice sound characteristics can be quantified in a reproducible and language-independent way. The high resolution of the method was verified by a computerized assignment of speech parameter patterns to languages at a success rate of 90%, while the correct assignment to texts was 70%. In the longitudinal self-assessment study we calculated individual 'baselines' for each test person along with deviations thereof. The significance of such deviations was assessed through the normative reference data.

CONCLUSIONS

Our data provided gender-, age-, and language-specific thresholds that allow one to reliably distinguish between 'natural fluctuations' and 'significant changes'. The longitudinal self-assessment study with repeated assessments at 1-day intervals over 14 days demonstrated the feasibility and efficiency of the speech analysis method in home environments, thus clearing the way to a broader range of applications in psychiatry.

Pharmacological management of unipolar depression

OBJECTIVE

To be used in conjunction with 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of pharmacological treatments in depression derived from a literature review.

METHOD

Using our previous Clinical Practice Guidelines [Malhi et al. Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand 2009;119(Suppl. 439):27-46] as a foundation, these clinician guidelines target key practical considerations when prescribing pharmacotherapy. A comprehensive review of the literature was conducted using electronic database searches (PubMed, MEDLINE), and the findings have been synthesized and integrated alongside clinical experience.

RESULTS

The pharmacotherapy of depression is an iterative process that often results in partial and non-response. Beyond the initiation of antidepressants, the options within widely used strategies, such as combining agents and switching between agents, are difficult to prescribe because of the paucity of pertinent research. However, there is some evidence for second-line strategies, and a non-prescriptive algorithm can be derived that is based broadly on principles rather than specific steps.

CONCLUSION

Depression is by its very nature a heterogeneous illness that is consequently difficult to treat. Invariably, situation-specific factors often play a significant role and must be considered, especially in the case of partial and non-response. Consulting with colleagues and trialling alternate treatment paradigms are essential strategies in the management of depression.

Vocal acoustic biomarkers of depression severity and treatment response

BACKGROUND

Valid, reliable biomarkers of depression severity and treatment response would provide new targets for clinical research. Noticeable differences in speech production between depressed and nondepressed patients have been suggested as a potential biomarker.

METHODS

One hundred five adults with major depression were recruited into a 4-week, randomized, double-blind, placebo-controlled research methodology study. An exploratory objective of the study was to evaluate the generalizability and repeatability of prior study results indicating vocal acoustic properties in speech may serve as biomarkers for depression severity and response to treatment. Speech samples, collected at baseline and study end point using an automated telephone system, were analyzed as a function of clinician-rated and patient-reported measures of depression severity and treatment response.

RESULTS

Regression models of speech pattern changes associated with clinical outcomes in a prior study were found to be reliable and significant predictors of outcome in the current study, despite differences in the methodological design and implementation of the two studies. Results of the current study replicate and support findings from the prior study. Clinical changes in depressive symptoms among patients responding to the treatments provided also reflected significant differences in speech production patterns. Depressed patients who did not improve clinically showed smaller vocal acoustic changes and/or changes that were directionally opposite to treatment responders.

CONCLUSIONS

This study supports the feasibility and validity of obtaining clinically important, biologically based vocal acoustic measures of depression severity and treatment response using an automated telephone system.

Acoustic analysis of the effects of sustained wakefulness on speech

Exposing healthy adults to extended periods of wakefulness is known to induce changes in psychomotor functioning [Maruff et al. (2005). J. Sleep Res. 14, 21-27]. The effect of fatigue on speech is less well understood. To date, no studies have examined the pitch and timing of neurologically healthy individuals over 24 h of sustained wakefulness. Therefore, speech samples were systematically acquired (e.g., every 4 h) from 18 healthy adults over 24 h. Stimuli included automated and extemporaneous speech tasks, sustained vowel, and a read passage. Measures of timing, frequency and spectral energy were derived acoustically using PRAAT and significant changes were observed on all tasks. The effect of fatigue on speech was found to be strongest just before dawn (after 22 h). Specifically, total speech time, mean pause length, and total signal time all increased as a function of increasing levels of fatigue on the reading tasks; percentage pause and mean pause length decreased on the counting task; F4 variation decreased on the sustained vowel tasks /a:/; and alpha ratio increased on the extemporaneous speech tasks. These findings suggest that acoustic methodologies provide objective data on central nervous system functioning and that changes in speech production occur in healthy adults after just 24 h of sustained wakefulness.

Clinical practice recommendations for depression

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

Psychomotor symptoms in depression: a diagnostic, pathophysiological and therapeutic tool

BACKGROUND

Psychomotor disturbances have been described repeatedly over many centuries. More recently, Sobin and Sackeim [Sobin, C., Sackeim, H.A., 1997. Psychomotor symptoms of depression. Am. J. Psychiatry. 154, 4-17.] discussed the relevance of psychomotor symptoms in depression in an extensive review. Since their report, new pathophysiological, diagnostic and therapeutic findings have been published. In the current review of the recent literature, we aim to argue the importance of psychomotor symptoms in depression and propose directions for future research.

METHOD

A review of all the relevant reports on this topic, published between 1996 and 2006, was conducted.

RESULTS

Several assessment methods demonstrate the diagnostic and pathophysiological significance of psychomotor symptoms. Antidepressants show differential effects on psychomotor performance and findings concerning the symptoms' predictive capacity for clinical response are contradictory. Numerous imaging studies as well as studies on the neurotransmitter systems and the HPA-axis contribute to the elucidation of the neurobiological processes underlying impaired psychomotor functioning in depression.

CONCLUSIONS

Psychomotor disturbances are of great diagnostic significance for the depressive subtype of melancholia. To enhance the conceptualisation of the construct 'psychomotor' a standardised battery for their assessment is recommended. As to the symptoms' predictive therapeutic power, to date research into functional outcome and studies applying objective experimental assessment methods are lacking. Moreover, the reported pathophysiological importance of dopamine for 'retarded depression' still warrants translation to the daily practice.

Timing of clinical improvement and symptom resolution in the treatment of major depressive disorder. A replication of findings with the use of a double-blind, placebo-controlled trial of Hypericum perforatum versus fluoxetine

BACKGROUND

Our objective was to assess for the relationship between timing of clinical improvement and resolution of depressive symptoms during the treatment of major depressive disorder (MDD). Thirty-nine MDD outpatients who responded following a 12-week, double-blind study comparing Hypericum perforatum, fluoxetine or placebo were included in the analysis.

METHODS

Onset of clinical improvement was defined as a 25% decrease in 17-item Hamilton Depression Scale (HDRS-17) scores that was not followed by a subsequent worsening of symptoms. Controlling for baseline symptom severity, we then assessed for the relationship between timing of clinical improvement and depressive symptom severity at endpoint.

RESULTS

Among responders, earlier clinical improvement predicted lower HDRS-17 scores at week 12 (p = 0013). This was also true of responders who received active treatment (n = 29, p = 0.0113) but not placebo responders (n = 10; p > 0.05). Finally, patients with an early onset of clinical improvement (occurring during the first 2 weeks) had lower week 12 HDRS-17 scores than patients with a late onset of clinical improvement (p = 0.0404).

CONCLUSION

In the present work, earlier as well as early clinical improvement during treatment is predictive of greater symptom resolution at endpoint among responders. This was replicated among patients who received active treatment (either hypericum or fluoxetine) but not placebo.

Timing of clinical improvement and symptom resolution in the treatment of major depressive disorder

The goal of the present work is to assess for the relationship between the timing of clinical improvement and the resolution of depressive symptoms in Major Depressive Disorder (MDD). 182 MDD outpatients (40.5+/-9.7 years; 53.8% female) who responded following an 8-week, 20 mg, open trial of fluoxetine were included in the analysis. The symptoms questionnaire (SQ) and Beck hopelessness scale (BHS) were also administered to 83 and 153 of these patients, respectively. Onset of clinical improvement was defined as a 30% decrease in 17-item Hamilton depression scale (HDRS-17) scores. Controlling for baseline symptom severity, we then assessed for the relationship between the timing of clinical improvement and depressive symptom at endpoint. Earlier clinical improvement in responders predicted lower HDRS-17, BHS, SQ-depression, SQ-anxiety, but not SQ-somatic symptom or SQ-anger/hostility scores at week 8. This was true regardless of whether improvement was defined as a continuous measure (30% decrease in symptom severity), as a dichotomous measure (clinical response occurring in the first two weeks of treatment). In conclusion, earlier clinical improvement with fluoxetine treatment is predictive of greater symptom resolution at endpoint. Further studies exploring the impact of various treatment modalities and placebo on the timing of clinical improvement and symptom resolution in MDD are warranted.

Voice acoustic measures of depression severity and treatment response collected via interactive voice response (IVR) technology

Efforts to develop more effective depression treatments are limited by assessment methods that rely on patient-reported or clinician judgments of symptom severity. Depression also affects speech. Research suggests several objective voice acoustic measures affected by depression can be obtained reliably over the telephone. Thirty-five physician-referred patients beginning treatment for depression were assessed weekly, using standard depression severity measures, during a six-week observational study. Speech samples were also obtained over the telephone each week using an IVR system to automate data collection. Several voice acoustic measures correlated significantly with depression severity. Patients responding to treatment had significantly greater pitch variability, paused less while speaking, and spoke faster than at baseline. Patients not responding to treatment did not show similar changes. Telephone standardization for obtaining voice data was identified as a critical factor influencing the reliability and quality of speech data. This study replicates and extends previous research with a larger sample of patients assessing clinical change associated with treatment. The feasibility of obtaining voice acoustic measures reflecting depression severity and response to treatment using computer-automated telephone data collection techniques is also established. Insight and guidance for future research needs are also identified.

A meta-analysis of early sustained response rates between antidepressants and placebo for the treatment of major depressive disorder

CONTEXT

Pattern analysis suggests that "true" drug response is characterized by clinical improvement that is not subsequently followed by a worsening of symptoms (sustained clinical response). To date, several reports demonstrate that early response rates are equivalent between antidepressant-treated and placebo-treated groups of patients with major depressive disorder, suggesting that patients who demonstrate significant and sustained symptom improvement during the first 2 weeks of treatment are not responding to the antidepressant itself, but to nonspecific, placebo-like factors.

OBJECTIVE

To compare early sustained response rates between antidepressant- and placebo-treated adults with major depressive disorder.

DATA SOURCES

Medline/Pubmed were searched. No year of publication limits were used.

STUDY SELECTION

Randomized, double-blind, placebo-controlled antidepressant trials or pooled reports/meta-analyses of such trials reporting early sustained response rates for major depressive disorder. The decision to include studies in the meta-analysis was performed by 2 reviewers.

DATA EXTRACTION

Data were extracted with the use of a precoded form.

DATA SYNTHESIS

Analyses were performed on the proportion of patients who achieved a sustained response the first 2 weeks of treatment, as well as the first week of treatment. A random-effects model with fixed drug effects was used to combine the studies and make comparisons of sustained early response rates between antidepressant- and placebo-treated groups. Data from 8 reports involving a total of 7121 major depressive disorder patients (4076 randomized to treatment with an antidepressant and 3045 randomized to placebo) were analyzed. Antidepressant-treated patients were more likely to demonstrate sustained clinical response by 2 weeks (odds ratio 2.06, 95% CI: 1.52-2.8) or 1 week of treatment (odds ratio 1.50, 95% CI: 1.08-2.08) than placebo-treated patients.

CONCLUSIONS

The results of the present analysis suggest that "true" drug response can occur the first 2 week as well as the first week of treatment of major depressive disorder with conventional antidepressants.

Remote capture of human voice acoustical data by telephone: a methods study

In this pilot study we sought to determine the reliability and validity of collecting speech and voice acoustical data via telephone transmission for possible future use in large clinical trials. Simultaneous recordings of each participant's speech and voice were made at the point of participation, the local recording (LR), and over a telephone line using a dedicated in-line computerized interactive voice recording system, the remote recording (RR). All voice recordings were made from our laboratory telephone located in Groton, Connecticut to the RR system located in Madison, Wisconsin. All data points were compared on a measure-by-measure basis between the LR and RR recordings. The results suggest that both measures of frequency excursion and of speech motor timing are reliably captured over the telephone. Results are discussed in terms of specific acoustic measures that may be useful and accurately measured via telephone transmission, for examining disease severity and pharmacological intervention for use in a large-scale clinical trial.

Voice acoustical measurement of the severity of major depression

A number of empirical studies have documented the relationship between quantifiable and objective acoustical measures of voice and speech, and clinical subjective ratings of severity of Major Depression. To further explore this relationship, speech samples were extracted from videotape recordings of structured interviews made during the administration of the 17-item Hamilton Depression Rating Scale (HDRS; ). Pilot data were obtained from seven subjects (five males, two females) from videotapes that have been used to train expert raters on the administration and scoring of the HDRS. Several speech samples were isolated for each subject and processed to obtain the acoustic measurements. Acoustic measures were selected on the basis that they were correlated with HDRS ratings of symptom severity as seen under ideal voice recording conditions in previous studies. Our findings corroborate earlier reports that speaking rate is well correlated (negatively) with HDRS scores, with a strong correlation and nearly significant trend seen for the measure of pitch variability. A moderate pairwise correlation between percent pause time and HDRS score was also revealed, although this relationship was not statistically significant. The results from this cross-sectional study further demonstrate the ability of voice and speech signal analyses to objectively track severity of depression. In the present case, it is suggested that this relationship is robust enough to be found despite the less than ideal recording conditions and equipment used during the original videotape recording. Voice acoustical analyses may provide a powerful compliment to the standard clinical interview for depression. Use of such measures increases the range of techniques that are available to explore the neurobiological substrates of Major Depression, its treatment, and the dynamic interplay of the systems that govern the motor, cognitive, and emotional aspects of speech production.

Feigned depression and feigned sleepiness: A voice acoustical analysis

We sought to profile the voice acoustical correlates of simulated, or feigned depression by neurologically and psychiatrically healthy control subjects. We also sought to identify the voice acoustical correlates of feigned sleepiness for these same subjects. Twenty-two participants were asked to speak freely about a cartoon, to count from 1 to 10, and to sustain an "a" sound for approximately 5s. These exercises were completed three times (within the same testing session) with three differing sets of instructions to the participants. These three conditions were presented in pseudo-random order to control for any order effects, and all subjects were naïve to the intended purpose of this study. For all three conditions, mean speaking rates and pitch ranges were calculated. A series of paired t tests showed significant differences in the speaking rates (counting numbers and free-speech exercises) between the 'normal' and feigned sleepy conditions, and between the normal and feigned depression conditions, but not between the 'sleepy' and 'depressed' conditions. The results for pitch range, for all speech exercises, were not different between the normal and either the feigned depression or feigned sleepiness conditions. These results indicate that persons feigning depression and sleepiness demonstrate some level of conscious control of their speech rate, but they did not convincingly alter their pitch ranges while feigning depression or sleepiness.

The impact of depression on social skills

Social skills deficits are common among depressed patients, but little attention has been paid to this aspect of depression. In this review, the potential roles of different depressive factors contributing to poor social skills are examined. Specifically, the first part of the analysis is focused on how different depressive factors influence the three components of social behavior: perceptual, cognitive, and performance. In the second part, evidence is provided to support the proposition that social skills deficits are manifestations of state depressive factors. This is based on results from studies involving mood induction procedures, counter manipulation procedures, and treatment with antidepressant drugs. These deficits are therefore likely to remit with effective treatment.

Affective disorder and epilepsy comorbidity: implications for development of treatments, preventions and diagnostic approaches

Concepts pertaining to affective disorder and epilepsy comorbidity are contributing appreciably to improvements in patient care. Several antiepileptic treatments have become important components of the management of bipolar affective disorder. In contrast, little progress has emerged in developing clinical applications of the anticonvulsant properties of the antidepressants in the treatment of the epilepsies. The slow onset of action of the antidepressants remains a major impediment to fully effective treatment of depressive episodes. Nevertheless, studies from experimental epileptology demonstrate that the anticonvulsant effects of the antidepressants occur rapidly and as a consequence of noradrenergic and/or serotonergic activation. These studies also demonstrate that adequate initial doses of the antidepressants are essential to rapid onset of anticonvulsant action. Pharmacokinetically valid loading dose paradigms are seemingly avoided with antidepressant drugs in humans because of potential toxicities and/or patient unacceptability. However, substantial progress has been made in reducing the adverse effect liability of the antidepressants. No longer is convulsive liability considered to stem from the therapeutic mechanisms of the anti-depressants. Rather, noradrenergic and serotonergic influences have demonstrable anticonvulsant properties. Other side effects may also be separable from the anticonvulsant and antidepressive effects of antidepressive treatments. The concept that the protracted process of antidepressant-induced beta-noradrenergic down-regulation is an essential prelude to the onset of mood benefit is no longer a sustainable premise. Nevertheless, increasing evidence underlies the possibility that knowledge of serotonergic and noradrenergic regulatory processes can be used to design strategies that will hasten the onset of antidepressive action. Similar optimism pervades efforts to determine the possibility that dual inhibition of serotonin and norepinephrine transporters will hasten onset of antidepressive action. Moreover, because noradrenergic and serotonergic systems are determinants of predisposition to seizures and to dysfunctional affective episodes, augmentation strategies may also be applicable to the use of antidepressant drugs in epilepsy and to the use of antiepileptic drugs such as carbamazepine in mood disorders. Recent studies have demonstrated that, in part, the therapeutic effectiveness of carbamazepine may stem from its marked capacity to elevate serotonin concentrations in the extracellular fluid of the brain via mechanisms that differ from those of the membrane reuptake inhibitors. Evidence suggests that the epilepsies and affective disorders may arise from a multiplicity of neurobiological abnormalities. A disorder in one individual may arise via different mechanisms than a phenomenologically similar disorder in another individual. Thus, diagnostic tools are needed to make mechanistic distinctions among individuals so that treatments can be appropriately developed and selected. In terms of epileptogenesis and affective disorder progression, neuroprotective paradigms for one individual may differ from those needed for another. Moreover, diagnostic technologies that are adequate to detect genetically and/or experientially determined vulnerability before the onset of a seizure or dysfunctional affective episode may be valuable steps toward achieving goals of prevention.

Communication of emotions in vocal expression and music performance: different channels, same code?

Many authors have speculated about a close relationship between vocal expression of emotions and musical expression of emotions. but evidence bearing on this relationship has unfortunately been lacking. This review of 104 studies of vocal expression and 41 studies of music performance reveals similarities between the 2 channels concerning (a) the accuracy with which discrete emotions were communicated to listeners and (b) the emotion-specific patterns of acoustic cues used to communicate each emotion. The patterns are generally consistent with K. R. Scherer's (1986) theoretical predictions. The results can explain why music is perceived as expressive of emotion, and they are consistent with an evolutionary perspective on vocal expression of emotions. Discussion focuses on theoretical accounts and directions for future research.

Reboxetine promotes social bonding in healthy volunteers

Reboxetine is a novel antidepressant with a selective action on noradrenaline. In addition to its efficacy in depression, it has been found to improve social adaptation. The objective of this study was to assess the specific social behavioural effects of reboxetine which might be associated with social adaptation. Ten pairs of healthy volunteers took part in a randomized double-blind, crossover study of 2 weeks treatment with reboxetine (4 mg b.d.) and placebo with a 2-week washout period. In each pair, one person (subject) took the tablets and the other (flatmate) received no treatment. On the last day of each treatment period, the subjects socially interacted with a stranger (a confederate behaving as a responsive person) in a stranger-dyadic social interaction paradigm. After the interaction, subjects played the Mixed-Motive game, which measures cooperative behaviour and communication, with the confederate. Subjects read a short story before and after the social interaction. The flatmates evaluated the social behaviour of the subjects before and at the end of the two treatment periods. On reboxetine, the subjects were rated to be significantly more agreeable and cooperative (passive participant) and less submissive by their flatmates. They showed significantly less eye contact with the confederate in the social interaction paradigm and gave significantly fewer helplessness messages during the game. They spoke faster on the reading task after the social interaction. This study provides evidence that reboxetine increases cooperative social behaviour and increases social drive, which might be important for social adaptation.

Development and validation of the Two-Dimensional Social Interaction Scale (2DSIS)

The Two-Dimensional Social Interaction Scale (2DSIS) is a newly developed 20-item observer rating scale to assess four distinct categories of social interaction: active participate; active non-participate; passive participate; and passive non-participate. The scale was submitted to a validation procedure based on video recording of 59 dyadic social interactions between a confederate enacting one of the four types of social behaviours and a participant. The 2DSIS observer ratings on the participants were associated with meaningful differences in participants' social behaviour and their scores on the Social Adaptation Self-evaluation Scale. The 2DSIS observer ratings on the confederates were associated with participants' Post Encounter Scale scores. Factor analysis suggested that the four category ratings did exist in the two dimensions as proposed. The 2DSIS could be used in conjunction with conventional assessment tools to evaluate the social functioning of individuals.

Serotonergic involvement in the psychosocial dimension of personality

Neurotransmitter systems have been associated with aspects of personality and changes in various dimensions have been shown after antidepressant treatment. A reduction in harm avoidance and an increase in self-directedness and cooperativeness, as measured by the Cloninger's Temperament and Character Inventory (TCI), have been reported in psychiatric patients receiving treatment with serotonergic antidepressants. However, some of these changes have been associated with clinical improvement. The present study therefore used a randomized, double-blind, placebo-controlled design to examine the role of the serotonergic system on these personality factors in the normal population. Twenty healthy male volunteers were randomly allocated to either placebo (n = 9) or citalopram treatment (n = 11) for 2 weeks. Baseline depression and anxiety scores were low and did not differ between groups. The TCI was administered pre- and post-treatment. There were no baseline differences on any TCI factor between groups. Citalopram induced a significant increase in self-directedness (p < 0.05) but not cooperativeness or harm avoidance ratings after treatment. Thus, citalopram has effects on personality aspects which appear to be separate from its antidepressant properties.