The timing, specificity and clinical prediction of tricyclic drug effects in depression

Electroconvulsive therapy improves somatic symptoms before mood in patients with depression: A directed network analysis

BACKGROUND

The recent network perspective of depression conceptualizes depression as a dynamic network of causally related symptoms, that contrasts with the traditional view of depression as a discrete latent entity that causes all symptoms. Electroconvulsive therapy (ECT) is an effective treatment for severe depression, but little is known about the temporal trajectories of symptom improvement during a course of ECT.

OBJECTIVE

To gain insight into the dynamics of depressive symptoms in individuals treated with ECT.

METHODS

The Quick Inventory of Depressive Symptomatology (QIDS) was used to assess symptoms twice a week in 68 participants with a unipolar or bipolar depression treated with ECT, with an average of 12 assessments per participant. Dynamic time warping (DTW) was used to analyze individual time series data, which were subsequently aggregated to calculate a directed symptom network and the in- and out-strength for each symptom.

RESULTS

Participants had a mean age of 49.6 (SD = 12.8) and 60% were female. Somatic symptoms (e.g., decreased weight) and suicidal ideation showed the highest out-strength values, indicating that their improvement tended to precede improvements in mood symptoms, which showed high in-strength. Sad mood had the highest in-strength, and thus appeared to be the last symptom to improve during ECT treatment (p < 0.001).

CONCLUSION

This study addresses a gap in the existing literature on ECT, by first analysing the temporal trajectories of symptoms within individual patients and subsequently aggregating them to the group level. The results show that somatic symptoms tend to improve before mood symptoms during ECT.

Replication of distinct trajectories of antidepressant response to intravenous ketamine

BACKGROUND

The goal of this study was to replicate previous findings of three distinct treatment response pathways associated with repeated intravenous (IV) ketamine infusions among patients with major depressive disorder (MDD).

METHODS

We conducted growth mixture modeling to estimate latent classes of change in depression (Quick Inventory of Depressive Symptomatology-Self Report, QIDS-SR) across six treatment visits in 298 patients with MDD treated with IV ketamine in an outpatient community clinic. Mean age was 40.36 and patients were primarily male (58.4 %). The sample had relatively severe depression (QIDS-SR = 16.61) at pre-treatment and the majority had not responded to at least two prior medications.

RESULTS

Best-fit indices indicated three trajectory groups to optimally demonstrate non-linear, quadratic changes in depressive symptoms during ketamine treatment. Two groups had severe depression at baseline but diverged into a group of modest improvement over the treatment course (n = 78) and a group of patients with rapid improvement (n = 103). A third group had moderate depression at baseline with moderate improvement during the treatment course (n = 117). Additional planned trajectory comparisons showed that suicidality at entry was higher in the high depression groups and that change in suicidality severity followed that of depression.

LIMITATIONS

This was a retrospective analysis of a naturalistic sample. Patients were unblinded and more heterogenous than those included in most controlled clinical trial samples.

CONCLUSIONS

This replication study in an independent community-based ketamine clinic sample revealed similar response trajectories, with only about a third of depressed patients benefitting substantially from an acute induction course of ketamine infusions.

Individual and common patterns in the order of symptom improvement during outpatient treatment for major depression

BACKGROUND

Research so far provided few clues on the order in which depressive symptoms typically remit during treatment. This study examined which depressive symptoms improve first, and whether symptoms changed before, simultaneous with, or after the core symptoms of depression (i.e., sad mood, loss of pleasure, and loss of interest).

METHODS

Participants were 176 patients with Major Depressive Disorder (MDD) receiving outpatient treatment (a combination of pharmacotherapy and psychological interventions) for depression. Participants filled out the Inventory of Depressive Symptomatology - Self Report (IDS-SR) for 16 to 20 consecutive weeks. For each symptom, the timing of onset of a persistent improvement was determined for each single-subject separately.

RESULTS

Which symptoms improved first differed markedly across patients. The core depression symptoms improved 1.5 to 2 times more often before (48% - 60%) than after (19% -28%) depressive cognitions ('view of myself' and 'view of the future'), anxiety symptoms ('feeling irritable' and 'feeling anxious / tense') and vegetative symptoms ('loss of energy', 'slowed down', and 'physical energy'). Only improvements in suicidal thoughts were more likely to occur before (46% - 48%) than after (29%) improvements in the depression core symptoms.

LIMITATIONS

Not all 'core depression-non-core symptom' combinations could be tested because some symptoms did not improve in a sufficient number of patients.

CONCLUSIONS

Which improvements mark the start of symptom remission differed between patients. Improvements in the core depression symptoms 'sad mood', 'loss of interest', and 'loss of pleasure' were more likely to occur before than after improvements in non-core symptoms.

Comparing onset of effect of antidepressants: Pragmatic considerations on methods and end-points

There is no accepted definition of what constitutes onset of antidepressant effect, and this limits evaluation of the validity of many comparative reports. In order to clarify the nature of the comparative methodology required, it is proposed that two distinct research questions are separated conceptually: 1) when do antidepressant drugs begin to clinically act? and 2) do all antidepressant drugs produce relief of symptoms in patients within a similar time period? A methodological distinction may also be made in terms of whether to assess the onset of effect of an antidepressant as having an absolute quality (“fast”) or as being fast relative to other treatments (“faster”). The choice of aim will help to define the methodological approach, the applicability of the findings and the difficulties to be addressed. Describing an antidepressant as showing a “fast” or “faster” onset of response requires that any description attempts to define (in terms that may be generalised) the nature of the comparison (faster than what?), the nature of the effect (faster to do what?) and the population in whom this effect may be expected (faster in whom?). Some details of methodological approaches are reviewed, and suggestions for study designs are made.

A regression analytical approach to estimate the onset of activity of antidepressants

The onset of activity of antidepressants is a clinically and theoretically important criterion of efficacy. We estimated the onset of activity by an intraindividual regression analytical approach. It is assumed that efficient treatment causes a fast shift of depression scores from a baseline level to an end level. From this assumption follows a limited number of opportunities for the onset of activity to occur. These opportunities correspond to different regression models which are estimated for each patient's depression course. The day of onset is concluded from the regression model which produces the best fit to the empirical depression curve. Results of a double-blind clinical trial comparing mianserin and amitriptyline are reported (n = 28). The methodological approach confirms that observer ratings by physicists show a significantly earlier onset of activity than self ratings by the patients. The D-S also shows a significantly earlier onset of activity of mianserin compared to amitriptyline. The discussion emphasises methodological aspects.

Initial response to active drug and placebo predicts outcome of antidepressant treatment

In this study we tested whether initial clinical change (ICC) and initial subjective response (ISR) predict the outcome of antidepressant pharmacotherapy and whether ICC and ISR as predictors reflect specific pharmacological actions or a placebo effect. Forty patients with major depression were treated with three different antidepressants for 4 weeks. Overall clinical change and final subjective response were taken as outcome criteria. The patients were randomly assigned to two subgroups in a double-blind design. Initially, one group received the active drug and the other placebo. Afterwards, all patients were given the active drug. Significant correlations were found between ICC and ISR and at least one of the outcome criteria in the total sample and in each subgroup. The findings show that ICC and ISR may be significant predictors of outcome. The predictive value of ICC and ISR is not due to initial pharmacological effects, but to non-specific treatment factors.

Delayed onset of action of antidepressant drugs? Survey of recent results

The onset of action of antidepressant drugs was investigated on the basis of two independent multicenter, double-blind efficacy studies comparing amitriptyline (n = 120), oxaprotiline (n = 120), imipramine (n = 506) and moclobemide (n = 580) with placebo (n = 189 + 191). The samples consisted of in- and outpatients diagnosed, according to Diagnostic and Statistical Manual (DSM)-III criteria, as suffering from major depressive disorder. Measures of efficacy criteria were the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A) and the Zung Self-Rating Depression scale. By using the Sustained Relative Improvement (SRI) criterion, onset of action was determined in each individual patient as that time point in the 30 day observation period at which a 20% baseline score reduction was achieved without subsequent deterioration. Analogously, a response to treatment was defined as a 50% baseline score reduction. As expected, highly significant differences between active drugs and placebo were found with respect to the total number of improvers and responders. Significant differences between treatment modalities surfaced in the percentage rate as well as the time distribution of premature withdrawals. Yet, unexpectedly, among improvers, the time spans to onset of improvement were found to be independent of treatment modality as indicated by virtually identical cumulative percentages of improvers throughout the whole observation period. The picture was essentially the same for the HAM-A and Zung assessments, except for a significant time lag between observer- and self-ratings. In particular, our analyses revealed no evidence for a delayed onset of action under various antidepressants with large biochemical and pharmacological differences in comparison to placebo. Moreover, the early onset of improvement was highly predictive of later outcome: on average, 70% of the patients showing improvement within the first 14 days became responders. Applying survival-analytical methods, we found that differences between active treatments and placebo emerged within the first 5 days and reached a point of maximum distinction around day 14. After this time point, differences between treatment modalities remained constant until the end of the observation period. According to our data, 20–25% of the patients were, on average, ‘true’ drug responders, thus suggesting that the therapeutic qualities of antidepressants do not lie in the suppression of symptoms, but rather are related to their ability to elicit and maintain certain conditions which allow recovery in a subgroup of patients who would otherwise remain non-responders.

On lightening up: improvement trajectories in recovery from depression

This article is an extended consideration of a recent editorial (Parker, 1996), and seeks to argue the importance of studying both onset and trajectories of improvement in those with depressive disorders.

Leptin receptor deficiency confers resistance to behavioral effects of fluoxetine and desipramine via separable substrates

Depression is a complex, heterogeneous mental disorder. Currently available antidepressants are only effective in about one-third to one-half of all patients. The mechanisms underlying antidepressant response and treatment resistance are poorly understood. Recent clinical evidence implicates the involvement of leptin in treatment response to antidepressants. In this study, we determined the functional role of the leptin receptor (LepRb) in behavioral responses to the selective serotonergic antidepressant fluoxetine and the noradrenergic antidepressant desipramine. While acute and chronic treatment with fluoxetine or desipramine in wild-type mice elicited antidepressant-like effects in the forced swim test, mice null for LepRb (db/db) displayed resistance to treatment with either fluoxetine or desipramine. Fluoxetine stimulated phosphorylation of Akt(Thr308) and GSK-3β(Ser9) in the hippocampus and prefrontal cortex (PFC) of wild-type mice but not in db/db mice. Desipramine failed to induce measurable changes in Akt, GSK-3β or ERK1/2 phosphorylation in the hippocampus and PFC, as well as hypothalamus of either genotype of mice. Deletion of LepRb specifically from hippocampal and cortical neurons resulted in fluoxetine insensitivity in the forced swim test and tail suspension test while leaving the response to desipramine intact. These results suggest that functional LepRb is critically involved in regulating the antidepressant-like behavioral effects of both fluoxetine and desipramine. The antidepressant effects of fluoxetine but not desipramine are dependent on the presence of functional LepRb in the hippocampus and cortex.

Use of mental health telemetry to enhance identification and predictive value of early changes during augmentation treatment of major depression

Standard clinical trial methodology in depression does not allow for careful examination of early changes in symptom intensity. The purpose of this study was to use daily "Mental Health Telemetry" (MHT) to prospectively record change in depressive and anxiety symptoms for depressed patients receiving augmentation treatment, and determine the extent and predictive capacity of early changes. We report results of a 6-week, open-label study of the addition of quetiapine XR (range, 50-300 mg) for adult patients (n = 26) with major depressive disorder who were nonresponsive to antidepressant treatment. In addition to regular study visits, all participants completed daily, wirelessly transmitted self-report ratings of symptoms on a Smartphone. Daily and 3-day moving average mean scores were calculated, and associations between early symptom change and eventual response to treatment were determined. Improvement in depressive and anxiety symptoms was identified as early as day 1 of treatment. Of the total decline in depression severity over 6 weeks, 9% was present at day 1, 28% at day 2, 39% at days 3 and 4, 65% at day 7, and 80% at day 10. Self-report rating of early improvement (≥20%) in depressive symptoms at day 7 significantly predicted responder status at week 6 (P = 0.03). Clinician-rated depressive and anxiety symptoms only became significantly associated with responder status at day 14. In conclusion, very early changes in depressive symptoms were identified using MHT, early changes accounted for most of total change, and MHT-recorded improvement as early as day 7 significantly predicted response to treatment at study end point.

Trajectories of individual symptoms in remitters versus non-remitters with depression

BACKGROUND

It remains unclear regarding the contribution of each individual symptom in predicting the outcome in major depressive disorder (MDD). The objective of this analysis was to evaluate trajectories of individual symptoms over time to identify which specific depressive item(s) could predict subsequent clinical response.

METHODS

The data of 2874 outpatients with nonpsychotic MDD who received citalopram for up to 14 weeks in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial were analyzed. Average trajectories of individual symptoms over time were estimated for remitters and non-remitters. Moreover, specific symptoms whose improvement at week 2 predicted remission were identified, using binary logistic regression analysis.

RESULTS

Trajectories were significantly different between remitters and non-remitters in all depressive symptoms. All depressive symptoms in the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) in the two groups, except for hypersomnia and weight change in non-remitters, substantially improved within 2 weeks and gradually continued to improve thereafter throughout the 14 weeks. Early improvements in the following five symptoms, in order of magnitude, in the QIDS-SR16 were significantly associated with remission: sad mood, negative self-view, feeling slowed down, low energy, and restlessness (P<0.001, P<0.001, P=0.001, P=0.004, P=0.021).

LIMITATIONS

The participants were limited to the nonpsychotic MDD outpatients who received citalopram. Further, symptomatology was not evaluated at the very beginning of treatment.

CONCLUSIONS

While the data pertain to citalopram and replication is necessary for other antidepressants, early improvements in certain core depressive symptoms may serve as a predictor of subsequent remission.

Is it worth assessing progress as early as week 2 to adapt antidepressive treatment strategy? Results from a study on agomelatine and a global meta-analysis

CONTEXT

A delay of 4-8weeks before modifying the prescribed antidepressant treatment is usually proposed when incomplete treatment response is observed. A number of studies nevertheless proposed that the lack of early improvement (usually 20% decrease of severity at week 2) is predictive of the absence of subsequent treatment response, potentially saving weeks of inadequate treatment, but with no information for non-interventional studies devoted to outpatients.

METHOD

Two thousand nine hundred and thirty-eight outpatients with major depressive disorder were included in a multicentre, non-interventional study, assessing at inclusion, week 2 and week 6, mood (QIDS-C, CGI, PGI and VAS) sleep (LSEQ) and functionality (SDS). All metrics at week 2 were tested for their capacity to predict response (and then remission) at week 6, all patients being treated by agomelatine. A meta-analysis of all studies (n=12) assessing the predictive role of improvement at week 2 was also performed, assessing specific effect size of published studies and the weight of the different parameters they used.

RESULTS

The QIDS-C and the CGI-I were the only instruments with an area under the curve over 0.7, with different cut-offs for treatment response and remission. A decrease of more than five points at the QIDS-C had the highest positive predictive value for treatment response, and a CGI-I over three had the highest negative predictive value, which would favour relying on the clinicians for warning (too high CGI-I), and on instruments for confidence (favourable decrease of the QIDS-C). The meta-analysis of all studies also detected a large effect size of early improvement, stressing how rating week 2 severity could be beneficial in clinical practice.

CONCLUSIONS

Previous reports stressing the interest of an assessment at week 2 were reinforced by the present results, which also defined more accurately what could be the most appropriate cut-offs, and how combining these early results could be more effective.

Early prediction of fluoxetine response for Han Chinese inpatients with major depressive disorder

The onset of antidepressant action is vital clinically. This study aimed to testify whether early symptom improvement can predict eventual treatment response at week 6 among depressive hospitalized patients taking fluoxetine. One hundred thirty-one hospitalized patients with major depressive disorder received 20 mg/d of fluoxetine for 6 weeks. Symptom severity was assessed by the 17-item Hamilton Depression Rating Scale (HAMD-17) at weeks 0, 1, 2, 3, 4, and 6. Stable response was defined as a reduction of 50% or more in the HAMD-17 total score at weeks 4 and 6 of treatment. Receiver operating characteristic curve was used to determine the cutoff point of the percentage of HAMD-17 score reduction between stable responders and nonresponders at weeks 1, 2, 3, and 4. At weeks 1, 2, 3, and 4, HAMD-17 score reductions of 25%, 39%, 43%, and 50% seemed to be the optimal cutoff points for predicting eventual response. They provided a sensitivity of 78%, 86%, 91%, and 93% and a specificity of 61%, 74%, 76%, and 92%. The percentage of HAMD-17 reduction at week 4 excellently predicted final response at week 6. Patients with less than a 50% symptom reduction during the first 4 weeks of treatment are unlikely to reach a final stable response. Whether this model can be applied to establish a prediction system for other antidepressants or for outpatients warrants further research.

Neuropsychological changes and treatment response in severe depression

BACKGROUND

Impaired neuropsychological function and differences in facial emotion processing are features of major depression. Some aspects of these functions may change during treatment and may be useful in assessing treatment response, even at an early stage of treatment.

AIMS

To examine early and later changes in neuropsychological functioning and facial emotion processing as potential markers of treatment response in major depression.

METHOD

In total, 68 newly admitted in-patients with a primary diagnosis of major depression and 50 healthy controls completed an assessment, including mood ratings, neuropsychological measures and facial emotion processing measures at three time points (baseline, 10-14 days and 6 weeks).

RESULTS

Pervasive neuropsychological impairment was evident at baseline in patients with depression compared with healthy controls. During 6 weeks of treatment, only simple reaction time, verbal working memory and the recognition of angry facial expressions showed differential change in those whose depression responded to treatment compared with treatment non-responders in the depression group. None of the measures showed a significant difference between treatment responders and non-responders at 10-14 days.

CONCLUSIONS

Despite significant impairment in neuropsychological functioning in the depression group, most measures failed to differentiate between treatment responders and non-responders at 10-14 days or at 6 weeks. Simple reaction time, verbal working memory and recognition of angry facial expressions may be useful in assessing response in severe depression but probably not at an early stage.

Accelerating response to antidepressant treatment in depression: a review and clinical suggestions

OBJECTIVE

The primary objective of this article is to review the literature regarding the speed of response to antidepressant drugs and potential strategies to accelerate the antidepressant response in new antidepressant-free patients with depression. Based on these data, we try to propose both an effective and safe antidepressant treatment strategy to alleviate depressive symptoms at the earliest opportunity.

DATA SOURCES

Data were identified by searches of Medline (1966 to September 2009) and references from relevant articles and books. Search terms included depression, antidepressant, predictor, response, onset, acceleration, and augmentation. As our focus was on the acute phase treatment of depression, articles relevant to treatment-resistant depression were excluded. Only articles written in English or Japanese were consulted.

DATA SELECTION

Studies, reviews, and books pertaining to the treatment of depression with a special regard to accelerating therapeutic effects were selected.

DATA SYNTHESIS

Most of the available treatment guidelines for major depressive disorders recommend the continuous use of antidepressants for 4 to 8 weeks based on the idea of a delayed onset of response to these drugs. Contrary to this conventional belief, the recent data indicate that antidepressants start to exert their effects within 2 weeks and early non-response could predict a subsequent unfavorable outcome.

CONCLUSIONS

These findings suggest the need of revisiting the timing of an antidepressant switch for early non-responders, whereby switching could be commenced in as early as 2 weeks.

The Timing of Antidepressant Effects: A Comparison of Diverse Pharmacological and Somatic Treatments

Currently available antidepressants used to treat major depressive disorder (MDD) unfortunately often take weeks to months to achieve their full effects, commonly resulting in considerable morbidity and increased risk for suicidal behavior. Our lack of understanding of the precise cellular underpinnings of this illness and of the mechanism of action of existing effective pharmacological treatments is a large part of the reason that therapies with a more rapid onset of antidepressant action (ROAA) have not been developed. Other issues that need to be addressed include heterogeneous clinical concepts and statistical models to measure rapid antidepressant effects. This review describes the timing of onset of antidepressant effects for various therapies used to treat MDD. While several agents produce earlier improvement of depressive symptoms (defined as occurring within one week), the response rate associated with such agents can be quite variable. These agents include both currently available antidepressants as well as other pharmacological and non-pharmacological interventions. Considerably fewer treatments are associated with ROAA, defined as occurring within several hours or one day. Treatment strategies for MDD whose sustained antidepressant effects manifest within hours or even a few days would have an enormous impact on public health.

Rethinking depression and the actions of antidepressants: uncovering the links between the neural and behavioral elements

Despite major strides in the understanding of mechanisms of antidepressant drug action, few, if any, widely applicable drug treatments with new mechanisms have been developed since the selective serotonin reuptake inhibitors in the late 1970's. One factor that may contribute to this lack of advance is reliance on a set of flawed assumptions that have guided most new drug development over the past quarter century. These assumptions have been particularly deleterious to the development of treatments with mechanisms distinctly different from currently approved treatments. One such assumption is that antidepressant actions on clinical aspects are delayed for several weeks. We review the results of studies on time to improvement and describe two collaborative, multidisciplinary studies during this period which employed a behavioral component model for assessment of change, as an alternative to the conventional "diagnostic-specific" research model. These studies incorporated a novel neurobehavioral framework for describing depressive episodes. The studies indicated that (1) depressive states are comprised of relatively independent and somewhat opposed behavioral and emotional components of anxiety-agitation and depression-retardation, coexisting with a third dimension, hostility, all of which might indicate some degree of mixed state phenomenology, (2) drugs selectively targeted at serotonergic and noradrenergic systems have differing profiles of impact on the behavioral dimensions of depressive states and (3) the sequence of behavioral improvements initiated by pharmacodynamically different drugs also differ. In the aggregate these consistent observations provide the basis for a new paradigm on the nature of major depression. The proposition links drug-induced neural and behavioral changes of antidepressants with prediction of clinical outcome based on early response. We submit that the proposed approach may bring about a new paradigm for improving behavioral technology and design of studies capable of identifying drugs with novel properties and rapid onset of improvement, while avoiding some problematic constructs in past biological research on depression.

Diurnal mood variation in outpatients with major depressive disorder

BACKGROUND

Diurnal mood variation (DMV) with early morning worsening is considered a classic symptom of melancholic features of major depressive disorder (MDD) according to the Diagnostic and Statistical Manual. This report used data from the sequenced treatment alternatives to relieve depression study to determine whether DMV was associated with treatment outcome to citalopram.

METHODS

Two thousand eight hundred and seventy-five outpatients with nonpsychotic MDD were evaluated during a 14-week trial of the selective serotonin reuptake inhibitor citalopram. Participants were divided into three groups: those with "classic" DMV (early morning worsening), those with any form of DMV (morning, afternoon, or evening worsening), and those with no DMV. Participants with classic DMV and those with any form of DMV were compared to those with no DMV in terms of baseline sociodemographic and clinical characteristics, treatment outcomes, and treatment features.

RESULTS

Minor baseline clinical characteristics and treatment feature differences were found between participants with and without DMV. Participants with classic morning DMV had slightly higher response rates than those without DMV. However, no differences were found in response or remission between either group of participants with DMV and those with no DMV.

CONCLUSION

DMV does not appear to be associated with a unique prominent pattern of response to selective serotonin reuptake inhibitor treatment in patients with depression, and does not appear to be a serotonergically modulated process. Further evaluation is necessary to determine if this relationship holds true for dopaminergic and noradrenergic antidepressant agents, such as dual-acting agents or antidepressant medication combinations.

[Review of the guidelines of the Brazilian Medical Association for the treatment of depression (Complete version)]

OBJECTIVE

Depression is a frequent, recurrent and chronic condition with high levels of functional disability. The Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present a review of the Guidelines Published in 2003 incorporating new evidence and recommendations.

METHOD

This review was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. The Brazilian Medical Association proposed this methodology for the whole project. The review was developed from new international guidelines published since 2003.

RESULTS

The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Strategies for different phases of treatment are also discussed.

CONCLUSION

The Guidelines are an important tool for clinical decisions and a reference for orientation based on the available evidence in the literature.

Psychosocial determinants of recovery in depression

There is a growing body of literature on residual symptoms after apparently successful treatment. The strong prognostic value of subthreshold symptomatology upon remission and the relationship between residual and prodromal symptomatology (the rollback phenomenon) have been outlined. Most residual symptoms also occur in the prodromal phase of depression and may progress to become prodromes of relapse. These findings entail important implications. It is necessary to closely monitor the patient throughout the different phases of illness and to assess the quality and extent of residual symptoms. A more stringent definition of recovery, which is not limited to symptomatic assessment, but includes psychological well-being, seems to be necessary. New therapeutic strategies for improving the level of remission, such as treatment of residual symptoms that progress to become prodromes of relapse and/or increasing psychological well-being, appear to yield more lasting benefits. The sequential model may provide room for innovative treatment approaches, including the use of drugs for specifically addressing residual symptoms. As occurs in other medical disorders (such as diabetes and hypertension), the active role of the patient in achieving recovery (self-therapy homework) should be pursued.

Rapid onset of antidepressant action: a new paradigm in the research and treatment of major depressive disorder

OBJECTIVE

Current therapeutics of depression are similar in their time to antidepressant action and often take weeks to months to achieve response and remission, which commonly results in considerable morbidity and disruption in personal, professional, family, and social life, as well as risk for suicidal behavior. Thus, treatment strategies presenting a rapid improvement of depressive symptoms--within hours or even a few days--and whose effects are sustained would have an enormous impact on public health. This article reviews the published data related to different aspects of rapid improvement of depressive symptoms.

DATA SOURCES

Literature for this review was obtained through a search of the MEDLINE database (1966-2007) using the following keywords and phrases: rapid response, antidepressant, time to, glutamate, sleep, therapeutics, latency, and depression. The data obtained were organized according to the following topics: clinical relevance and time course of antidepressant action, interventions showing evidence of rapid response and its potential neurobiological basis, and new technologies for better understanding rapid anti-depressant actions.

DATA SYNTHESIS

A limited number of prospective studies evaluating rapid antidepressant actions have been conducted. Currently, only a few interventions have been shown to produce antidepressant response in hours or a few days. The neurobiological basis of these rapid antidepressant actions is only now being deciphered.

CONCLUSIONS

Certain experimental treatments can produce antidepressant response in a much shorter period of time than existing medications. Understanding the molecular basis of these experimental interventions is likely to lead to the development of improved therapeutics rather than simply furthering our knowledge of current standard antidepressants.

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.

The role of neurotrophic factors in adult hippocampal neurogenesis, antidepressant treatments and animal models of depressive-like behavior

Major depressive disorder (MDD) is characterized by structural and neurochemical changes in limbic structures, including the hippocampus, that regulate mood and cognitive functions. Hippocampal atrophy is observed in patients with depression and this effect is blocked or reversed by antidepressant treatments. Brain-derived neurotrophic factor and other neurotrophic/growth factors are decreased in postmortem hippocampal tissue from suicide victims, which suggests that altered trophic support could contribute to the pathophysiology of MDD. Preclinical studies demonstrate that exposure to stress leads to atrophy and cell loss in the hippocampus as well as decreased expression of neurotrophic/growth factors, and that antidepressant administration reverses or blocks the effects of stress. Accumulating evidence suggests that altered neurogenesis in the adult hippocampus mediates the action of antidepressants. Chronic antidepressant administration upregulates neurogenesis in the adult hippocampus and this cellular response is required for the effects of antidepressants in certain animal models of depression. Here, we review cellular (e.g. adult neurogenesis) and behavioral studies that support the neurotrophic/neurogenic hypothesis of depression and antidepressant action. Aberrant regulation of neuronal plasticity, including neurogenesis, in the hippocampus and other limbic nuclei may result in maladaptive changes in neural networks that underlie the pathophysiology of MDD.

Bayesian modelling and ROC analysis to predict placebo responders using clinical score measured in the initial weeks of treatment in depression trials

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

* In major depressive disorder an appreciable percentage (40%) of patients in antidepressant trials will have a placebo response. * In these trials, early changes (i.e. within the first 4 weeks) of the clinical score scale (e.g. HAMD-17) are associated with response at end-point. * Unpredictable placebo response is one of the major reasons for clinical trial failure in the evaluation of antidepressant drugs.

WHAT THIS STUDY ADDS

* Provides a model to describe the time course of individual and population placebo response. * Provides a methodology to forecast the individual probability to be placebo responder based on early HAMD-17 measurements with an assessment of the prognostic power. * Provides a methodological framework to implement a population enrichment strategy in the design of clinical trials for the assessment of novel antidepressant drugs.

AIMS

To develop a probabilistic and longitudinal model describing the time course of Hamilton's Rating Scale for Depression (HAMD-17) total score in patients with major depressive disorders treated with placebo and to develop predictive models to estimate the response at end-point given HAMD-17 measurements at weeks 2 and 4.

METHODS

Patients (n = 691) from seven clinical trials were analysed in WinBUGS using a Bayesian approach. The whole dataset was randomly split in a learning (359 patients for model definition) and a test dataset (332 patients for assessment of model predictive performance). The analysis of the learning dataset assumed uninformative priors, whereas the analysis of the test dataset used the posterior parameter estimates of the learning dataset as priors. ROC curve analysis estimated the optimal sensitivity/specificity cut-off between false-negative and false-positive rates and determined the prognostic allocation rule for patients to responder and nonresponder groups.

RESULTS

A Weibull/linear model accurately described the population and individual HAMD-17 time course. The total area under the ROC curve, ranging from 0.76 (logistic model with data at week 2) to 0.86 (longitudinal model with data at week 4), provided a measure of the prognostic discriminatory power of early HAMD-17 measures using the two models. The best placebo-responder classification score (86.32% true and 13.68% false positive) was associated with the longitudinal model with HAMD-17 measures at week 4.

CONCLUSION

Results showed the relevance of the Bayesian approach to predict HAMD-17 score at study end and to classify a patient as a placebo responder given the uncertainty in parameters derived from historical data and early HAMD-17 measurements.

Assessing activity onset time and efficacy for clinically effective antidepressant and antimanic drugs in animal models based on dominant-submissive relationships

There is confusion in the literature on the measurement of the drug activity onset time (AOT) for both clinical and non-clinical studies of antidepressant and antimanic drugs. The questions asked are: How often and at which time points should drug effects be measured? At what level of a drug effect should AOT be determined? Is the placebo (control) effect important for consideration of drug AOT? This paper reviews approaches taken to answer these questions and to assess drug therapeutic AOT. The first part of the paper is devoted to a review of methods used in clinical trials with depression as an indication. The second part is focused on approaches taken in animal models of depression and how they could help in assessing drug AOT. Finally, a summary of pharmacological values on which the AOT depends is presented and a new statistical approach to data analysis method proposed. The allied experimental design for pre-clinical and clinical studies may help to characterize and differentiate AOT for available and new generation of antidepressants and antimanic drugs.

Prodromal stage of major depression

AIM

The aim of this review was to survey the available literature on prodromal symptoms of unipolar major depression.

METHODS

Both a computerized (Medline) and a manual search of the literature were performed.

RESULTS

In a substantial proportion of patients with depression a prodromal phase can be identified. There is a relationship between residual and prodromal symptomatology (the rollback phenomenon).

CONCLUSIONS

Appraisal of prodromal phase of major depression has important implications as to pathophysiological models of disease and relapse prevention. It may allow a staging system of depressive illness that may yield more enduring results in the therapeutic efforts.

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.

Early onset of selective serotonin reuptake inhibitor antidepressant action: systematic review and meta-analysis

CONTEXT

Selective serotonin reuptake inhibitors (SSRIs) are often described as having a delayed onset of effect in the treatment of depression. However, some trials have reported clinical improvement as early as the first week of treatment.

OBJECTIVE

To test the alternative hypotheses of delayed vs early onset of antidepressant action with SSRIs in patients with unipolar depression.

DATA SOURCES

Trials identified by searching CENTRAL, The Cochrane Collaboration database of controlled trials (2005), and the reference lists of identified trials and other systematic reviews.

STUDY SELECTION

Randomized controlled trials of SSRIs vs placebo for the treatment of unipolar depression in adults that reported outcomes for at least 2 time points in the first 4 weeks of treatment (50 trials from >500 citations identified). Trials were excluded if limited to participants older than 65 years or specific comorbidities.

DATA EXTRACTION

Data were extracted on trial design, participant characteristics, and outcomes by a single reviewer.

DATA SYNTHESIS

Pooled estimates of treatment effect on depressive symptom rating scales were calculated for weeks 1 through 6 of treatment. In the primary analysis, the pattern of response seen was tested against alternative models of onset of response. The primary analysis incorporated data from 28 randomized controlled trials (n=5872). A model of early treatment response best fit the experimental data. Treatment with SSRIs rather than placebo was associated with clinical improvement by the end of the first week of use. A secondary analysis indicated an increased chance of achieving a 50% reduction in Hamilton Depression Rating Scale scores by 1 week (relative risk, 1.64; 95% confidence interval, 1.2-2.25) with SSRI treatment compared with placebo.

CONCLUSIONS

Treatment with SSRIs is associated with symptomatic improvement in depression by the end of the first week of use, and the improvement continues at a decreasing rate for at least 6 weeks.

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.

Who receives antidepressants and what impact do they have? An acute-care study

The purpose of this study was to examine characteristics associated with prescribing antidepressants in major depression and the utility of such antidepressants in an acute-care, inpatient setting. Demographic and clinical (self-report and clinician-rated scales) were obtained for 111 inpatients diagnosed with major depression. Three comparison sets were made: (1) all patients prescribed antidepressants versus those who were not; (2) those in the top quartile for length of stay (LOS) versus those in the bottom quartile; and (3) patients discharged in less than one week who were prescribed versus not prescribed, antidepressants. Overall, minimal differences were found in the three comparison sets. Those prescribed antidepressants had higher admission BDI scores, longer LOS, more previous episodes, higher education levels, and were more likely to be admitted voluntarily. At admission, there were no clear predictors of LOS. Regardless of differences between groups at admission or discharge (antidepressant versus no antidepressant, short versus long LOS), no differences were found in the length of time before patients were readmitted. These findings suggest that the traditional practice of avoiding immediate medication at hospitalization appears to have some validity.

What should animal models of depression model?

In this article, we discuss what animal models of depression should be attempting to 'model'. One must first determine if the goal is to model the regulatory mechanisms by which antidepressant treatments alleviate the various symptoms of depression, or to model the dysregulatory mechanisms underlying the etiology of those symptoms. When modeling the mechanisms of antidepressant effects, a key feature that is often overlooked is the time course required for behavioral efficacy. Even in the clinical literature, there is considerable confusion and inconsistency in defining and identifying 'time of onset' of clinical effect. Although the 'therapeutic lag' may not be as long as has been commonly believed, it does occur. Observable improvement in either global symptomatology or specific symptoms becomes evident after 7-14 days of treatment, and more complete recovery takes considerably longer. Thus, any model addressing potential mechanisms of antidepressant action should exhibit a similar time-dependency. Second, whether attempting to address mechanisms underlying behavioral effects of antidepressants, or the neurobiological substrates underlying the development and manifestation of depression, it is essential to recognize that the syndrome of depression is a diagnostic construct that includes a variety of disparate symptoms, some of which may be related mechanistically, and others that may not be specific to depression, but may cut across categorical diagnostic schemes. Further, it is critical to recognize the close relationship of depression and anxiety. Psychological studies have suggested that the myriad symptoms of depression and anxiety may be subsumed within a more limited number of distinct behavioral dimensions, such as negative affect (neuroticism), positive affect, or physiologic hyperarousal. These dimensions may be related to the functioning of specific neurobiological systems. Thus, rather than trying to recreate or mimic the entire spectrum of symptoms comprising the syndrome of depression, it may be more informative to develop animal models for these behavioral dimensions. Such models may then provide access not only to the neural regulatory mechanisms underlying effective antidepressant treatment, but may also provide clues to the processes underlying the development and manifestation of depression.

The tail suspension test as a model for assessing antidepressant activity: review of pharmacological and genetic studies in mice

Since its introduction almost 20 years ago, the tail suspension test has become one of the most widely used models for assessing antidepressant-like activity in mice. The test is based on the fact that animals subjected to the short-term, inescapable stress of being suspended by their tail, will develop an immobile posture. Various antidepressant medications reverse the immobility and promote the occurrence of escape-related behaviour. This review focuses on the utility this test as part of a research program aimed at understanding the mechanism of action of antidepressants. We discuss the inherent difficulties in modeling depression in rodents. We describe how the tail suspension differs from the closely related forced swim test. Further, we address some key issues associated with using the TST as a model of antidepressant action. We discuss issues regarding whether it satisfies criteria to be a valid model for assessing depression-related behavioural traits. We elaborate on the tests' ease of use, strain differences observed in the test and gender effects in the test. We focus on the utility of the test for genetic analysis. Furthermore, we discuss the concept of whether immobility maybe a behavioural trait relevant to depression. All of the available pharmacological data using the test in genetically modified mice is collated. Special attention is given to selective breeding programs such as the Rouen 'depressed' mice which have been bred for high and low immobility in the tail suspension test. We provide an extensive pooling of the pharmacological studies published to date using the test. Finally, we provide novel pharmacological validation of an automated system (Bioseb) for assessing immobility. Taken together, we conclude that the tail suspension test is a useful test for assessing the behavioural effects of antidepressant compounds and other pharmacological and genetic manipulations relevant to depression.

What moderator characteristics are associated with better prognosis for depression?

A retrospective data analysis was conducted to evaluate the usefulness of baseline characteristics in predicting treatment response to antidepressant medication in 97 outpatients with nonpsychotic major depression treated for up to sixteen weeks with nefazodone. Baseline demographics (gender), illness features (symptom severity, length of illness, length of current episode, number of episodes, age of onset, longitudinal subtype, endogenicity, melancholia, family history of mood disorders), and social features (living status) were evaluated. Response to treatment was defined as a >/= 50% reduction in the 17-item Hamilton Rating Scale for Depression (HRSD(17)) score. The results of a survival analysis indicated that patients with shorter histories of illness (< 4 years), a negative family history of depression, and those who were either married or were living with someone were more likely to have a positive outcome during the acute phase treatment of depression. The main findings are consistent with extensive previous literature indicating a better short-term outcome of depression where illness is shorter, where there is no family history, and where there is better social support.

Onset of action for duloxetine 60 mg once daily: double-blind, placebo-controlled studies

BACKGROUND

It is widely believed that most antidepressant medications exhibit a delay of 2-4 weeks before clinically relevant improvement can be observed among patients. During this latency period, patients continue to be symptomatic and functionally impaired. Thus, time to onset of effect is an important attribute of a new pharmacotherapy. We assessed the onset of effect for duloxetine, utilizing analytical methods previously recommended in the literature.

METHOD

Efficacy data were pooled from two identical, but independent, randomized, double-blind, placebo-controlled, 9-week clinical trials of duloxetine (60 mg QD). Efficacy measures included the 17-item Hamilton Rating Scale for Depression (HAMD(17)), HAMD(17) subscales (Maier, core, and anxiety), and the Clinical Global Impression of Severity (CGI-S) and Patient Global Impression of Improvement (PGI-I) scales. In each individual study, duloxetine demonstrated statistically significant advantages over placebo on multiple outcomes. The present analysis utilized pooled data to more accurately and fully characterize the onset of effect for duloxetine.

RESULTS

Median times to sustained improvements of 10% and 20% in the HAMD(17) total score among duloxetine-treated patients were 14 days and 21 days, respectively, compared with 34 days and 49 days, respectively, for placebo-treated patients (p < 0.001 for both results). The median time to sustained 30% improvement in HAMD(17) total score was 35 days for duloxetine-treated patients, while the median time for placebo-treated patients was not estimable since less than half of the patients met this criterion by the end of the trial. For duloxetine-treated patients, median times to sustained 10%, 20%, and 30% improvements on the Maier subscale of the HAMD(17) were the same as those for the HAMD(17) total score: 14, 21, and 35 days, respectively. However, in other analyses, changes in core emotional symptoms as measured by subscales of the HAMD(17) were somewhat faster than changes in overall symptomatology. The probabilities of achieving a sustained 30% improvement (Maier subscale) at Week 1 for duloxetine- and placebo-treated patients were 16.2% vs. 4.8%, respectively (p < 0.001). The corresponding probabilities of sustained improvement at Weeks 2 and 3 for duloxetine were 32.5% and 45.4%, respectively, compared to 12.8% and 21.4% for placebo ((p < 0.001 for both comparisons).

CONCLUSION

The absence of an active comparator limits the conclusions which can be drawn regarding the rapidity of onset of clinically meaningful improvement. However, results from the present investigation may be useful to clinicians in consideration of treatment options for individual patients.

Improvement of anger at one week predicts the effects of sertraline and placebo in PTSD

In previous work we demonstrated an early, robust and sustained effect for sertraline vs placebo on irritability and anger in subjects with PTSD. In this report, we explore the same dataset to assess whether a clinician might usefully predict ultimate response to sertraline, on the basis of its effect upon anger after one week. Three hundred and eighteen subjects were assessed. Outcome was measured by whether or not the score was reduced by at least 50% from baseline. Ordinary least squares regression was used to estimate the effects of change in anger at one week. Logistic regression was applied to estimate the effects on odds of a 50% drop in score. Cut points were developed for one-week change scores on anger for sertraline and placebo. The best cut point was selected as predictive of non-response, i.e. a cue suggesting that treatment switch would be in order. An increase in anger of 30% at one-week best predicted the likelihood of not responding to treatment in both the drug and placebo groups. Twenty-five percent of all non-responders were incorrectly identified, while only 7% of all improvers were incorrectly categorized as non-responders using this cutoff. Our findings imply that, for patients similar to those in this study, an increase in anger after one week of treatment might be one factor to consider when making a decision about continuation of the medication.

A review of acute treatments for bipolar depression

Bipolar patients generally spend much more time in the depressed phase of their illness than the manic phase, and there are many more bipolar type II and bipolar spectrum disorder patients than there are bipolar type I. Additionally, there is a significant risk of suicide in bipolar patients when depressed. The treatment of the depressed phase of bipolar disorder is therefore a matter of some priority. Here, we review current evidence supporting the use of five groups of treatments: anti-depressants; lithium; anti-convulsants (valproate, and carbamazepine, lamotrigine, gabapentin); anti-psychotics; and other treatments (electroconvulsive therapy, benzodiazepines, sleep-deprivation, and dopamine agonists). From this review, it is apparent that the literature regarding the treatment of bipolar depression is significantly limited in several key areas. Nonetheless, from the evidence currently available, the treatments with the best evidence for efficacy are selective serotonin reuptake inhibitors (SSRIs) and lamotrigine. There is also some evidence in favour of bupropion and moclobemide. Although lithium and olanzapine monotherapies can also be beneficial, they appear less efficacious than antidepressants. One of the major concerns about treatment with antidepressants has been the risk of precipitating a switch into mania. However, recent studies suggest that, if a mood stabilizer and antidepressant are given concurrently, then the risk of switching is minimized. There is also recent evidence for an independent antidepressant action for at least one atypical antipsychotic. Therefore, the conclusion from this review, in contrast to previous suggestions, is that a combination of an atypical antipsychotic and either an SSRI or lamotrigine may provide a useful first-line treatment for depressed bipolar disorder patients. Further research is clearly required to examine this approach and compare it with other possible treatment options.

Onset and early behavioral effects of pharmacologically different antidepressants and placebo in depression

This study was aimed at resolving the time course of clinical action of antidepressants (ADs) and the type of early behavioral changes that precede recovery in treatment-responsive depressed patients. The first goal was to identify, during the first 2 weeks of treatment, the onset of clinical actions of the selective serotonin reuptake inhibitor (SSRI), paroxetine, and the selective noradrenergic reuptake inhibitor, desipramine (DMI). The second aim was to test the hypothesis that the two pharmacologic subtypes would induce different early behavioral changes in treatment-responsive patients. The design was a randomized, parallel group, placebo-controlled, double-blind study for 6 weeks of treatment following a 1-week washout period. The study utilized measures of the major behavioral components of the depressive disorder as well as overall severity. The results indicated that the onset of clinical actions of DMI ranged from 3 to 13 days, averaged 13 days for paroxetine, and was 16-42 days for placebo. Furthermore, as hypothesized, the different types of ADs initially impacted different behavioral aspects of the disorder. After 1 week of treatment, DMI produced greater reductions in motor retardation and depressed mood than did paroxetine and placebo, and this difference persisted at the second week of treatment. Early improvement in depressed mood-motor retardation differentiated patients who responded to DMI after 6 weeks of treatment from those that did not. Paroxetine initially reduced anxiety more in responders than in nonresponders, and by the second week, significantly improved depressed mood and distressed expression in responders to a greater extent. Depressed patients who responded to placebo showed no consistent early pattern of behavior improvement. Early drug-specific behavioral changes were highly predictive of ultimate clinical response to the different ADs, results that could eventually be applied directly to clinical practice.

[Guidelines of the Brazilian Medical Association for the treatment of depression (complete version)]

OBJECTIVE

Depression is a frequent and chronic condition with high levels of functional disability. Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present the original document that originated the abbreviated version available at the electronic address of Brazilian Medical Association.

METHODS

This paper was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. Brazilian Medical Association proposed this methodology for the whole project.

RESULTS

The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Planning of different phases of treatment is22 also discussed.

CONCLUSIONS

Guidelines are a good tool helping clinical decisions and are a reference for an attitude based on levels of evidence.

Challenges in the development of clinical trials for major depressive disorder: lessons learned from trials in minor depression

This paper reviews some of the challenges faced by individuals who design and implement clinical trials of potential antidepressant medications. Particular emphasis is placed on questioning the validity of some of the theoretical assumptions that form the underpinnings of most conventional trials. Work from our group developing clinical trial methodology for minor depression is used as an example of how alternate constructs may be helpful to differentiate drug-placebo differences.

Residual symptoms in depression: an emerging therapeutic target

Residual symptoms, despite successful response to therapy, appear to be the rule in unipolar depression. Most of the residual symptoms occur in the prodromal phase of illness. Residual symptoms are associated with biological correlates, mainly involving the hypothalamic-pituitary-adrenal (HPA) axis and the sleep architecture. They are powerful predictors of relapse. These findings have led to the hypothesis that residual symptoms upon recovery may progress to become prodromal symptoms of relapse. A sequential strategy (encompassing pharmacotherapy in the acute phase of illness and cognitive behavioral therapy in its residual phase) has been developed and was found to be effective in decreasing relapse rate in controlled studies. A largely untested assumption in unipolar depression is that pharmacological strategies that are effective in the short term are the most suitable for postacute and residual phases or maintenance. The literature on subclinical symptomatology calls for specific, stage-oriented, therapeutic approaches. The efficacy of antidepressant drugs may be assessed not only on differential remission rates, but also on differential amount of residual symptomatology after response.

Are bipolar I depressive patients less responsive to treatment with antidepressants than unipolar depressive patients? Results from a case control study

The increasing evidence that bipolar and unipolar affective disorders have different biological etiologies and courses of illness has been associated with an intensifying interest in specific treatment regimens for both disorders during the last decade. In this context, the question arose whether antidepressants exert similar efficacy in the acute treatment of bipolar compared to unipolar depression. Although the clinical impression does not indicate substantial differences in the efficacy of antidepressants between these groups of patients, empirical databases concerning this topic are rare. The present study compared the efficacy of antidepressants in 50 unipolar and 50 bipolar depressed inpatients (ICD-9 criteria) under naturalistic treatment conditions. Both groups of patients were matched for age, gender and duration of illness. Clinical assessments of status at the time of admission and at discharge were used to rate response to antidepressant treatment. Analyses of the data revealed that both groups of patients needed the same time for treatment response and did not show any significant differences in outcome measures at discharge. These findings do not concur with the hypothesis formulated by some experts in the field of affective disorders that antidepressants are less effective in the acute treatment of bipolar depressed patients compared to unipolar depressed patients.

Early and delayed personality changes associated with depression recovery? A one-year follow-up study

Many studies have shown the state effect of depression on personality. However, the chronology of personality changes associated with depression recovery remains unstudied. The objective of this study is to assess early (first month) and delayed personality changes associated with depression recovery. Fifty-seven depressed inpatients were assessed with the Temperament and Character Inventory (TCI) at admission, 1 month, and 1 year post-treatment. Patients were divided into poor and favorable outcome. No significant personality change was observed in patients with poor depression outcome. Conversely, a favorable outcome of depression was associated with early and delayed personality changes. Early changes were: decrease in Harm avoidance (HA(1):Worry and pessimism), increase in Cooperativeness and Self-directedness (SD(1):Responsibility, SD(4):Self-acceptance, SD(2):Purposefulness and SD(3):Resourcefulness). Delayed changes were changes in character: increase in Self-Directedness (SD(1):Responsibility, SD(4):Self-acceptance, SD(5): Congruent second nature), decrease in Self-transcendence (ST(2):Transpersonal identification). This study shows the different status of personality changes associated with depression recovery, and it contributes to a better knowledge of the state effect and of subtle clinical changes in patients who are recovering from depression. It may also have implications for the prediction of depression outcome.

Are antidepressants less effective in the acute treatment of bipolar I compared to unipolar depression?

BACKGROUND

Using our routine documentation system we evaluated the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I depressed patients compared to unipolar depressed patients.

METHOD

Based on the data from 2032 consecutively admitted inpatients with unipolar or bipolar I depression we compared the efficacy of antidepressants in both groups. The outcome was assessed by the Global assessment scale (GAS), the duration of hospitalisation and the Apathic-, Depressive- and Manic Syndrome subscales of the Association for Methodology and Documentation in Psychiatry system.

RESULTS

Cohorts were comparable in treatment regimens and severity of depression at admission. At discharge, there were no statistically significant differences between bipolar I and unipolar depression for the outcome criteria Depressive Syndrome scale, GAS score and days in hospital. Bipolar patients showed a slightly decreased score of the Apathic Syndrome scale at discharge, also reflected by a slightly elevated score of the Manic Syndrome scale.

LIMITATIONS

This study did not check for differences in side effects such as switching or cycling commonly attributed to the use of tricyclic antidepressants in bipolar patients. Naturalistic data were obtained prospectively, analysis, however, was done retrospectively, thus limiting, but not completely excluding a possible selection bias.

CONCLUSION

Evaluating different outcome criteria, our naturalistic data of a large cohort seem to reject the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I compared to unipolar depressed patients.