Recurrent depression: patient characteristics, clinical course, and current recommendations for management

Clinical predictors associated with full remission versus episode of major depressive disorder outpatients: the experience at a teaching hospital in Taiwan

BACKGROUND

When depressed patients are in remission, the clinical characteristics indicate that they are able to participate in social activities more regularly, and their impairment in daily functioning is improved. The present study examines the clinical characteristics associated with one- and two month clinical response in outpatients with Major Depressive Disorder (MDD) in Taiwan.

METHODS

A total of 160 outpatients were initially recruited from the medical centre in Taiwan. Of these participants, 151 MDD patients completed the baseline-assessment interview, 111 were interviewed and assessed again 4 weeks later, and 78 completed the final interview and assessment 8 weeks later. In the present study, asymptomatic was defined as scoring ≤ 7 on the Hamilton Depression Rating Scale (HAM-D); partially symptomatic was defined as scoring 8-14; fully symptomatic was defined as scoring ≥15. Finally, asymptomatic, partially symptomatic, and fully symptomatic were defined in patients with MDD respectively as in full remission, in persistent depressive symptom, and in episode.

RESULTS

Of the remaining 78 patients, a total of 21 (26.9%) were in full remission, 35 (44.9%) were in persistent depressive symptom, and 22 (28.2%) were in episode. Patients in full remission were older (p = 0.03), exhibited greater psychosocial functioning, (p < 0.001), held more-positive beliefs regarding antidepressant medication (p = 0.03), had higher self-efficacy (p = 0.001), and scored lower for neuroticism (p = 0.003), as compared to patients in episode. Younger patients were more prevalent in persistent depression. Repeated-measures ANOVA revealed that differences in four factors (psychosocial functioning, beliefs regarding antidepressant medication, self-efficacy in managing and preventing depression, and neuroticism) were significantly different between full remission and episode. Episode was significantly associated with psychosocial-functioning impairment (OR = 1.12, 95% CI: 1.00-1.26) and poorer self-efficacy (OR = 0.91, 95% CI: 0.82-1.00).

CONCLUSIONS

Our findings identify significant factors of full remission, persistent depressive symptom, and episode. We highlight the importance of enhancing patients' psychosocial functioning and self-efficacy until achieving full remission. Suggestions are provided for clinical health-care management services in Taiwan.

Tardive dysphoria: antidepressant-induced chronic depression

Objectives: A significant number of depressed individuals experience inadequate benefit from long-term antidepressant use. This paper investigates the hypothesis that in some individuals persistent use of antidepressants may be prodepressant.

Methods: Literature regarding the effect of long-term use of antidepressants was reviewed by searching PubMed and Ovid data bases with terms: antidepressant tachyphylaxis, treatment-resistant depression, chronic depression and antidepressant tolerance.

Results: Antidepressant treatment-resistant patients frequently had a positive initial response to antidepressants. When resistance appeared, initial increases in dose or medication changes usually resulted in transient improvement. Eventually, the episodic course of the original depressive illness was replaced with a continuous, unresponsive depressive syndrome. We propose the term tardive dysphoria to describe this phenomenon.

Conclusions: The phenomenon of antidepressantinduced depression, or tardive dysphoria, needs to be experimentally examined in blinded, randomised antidepressant discontinuation studies.

Investigating the genetic variation underlying episodicity in major depressive disorder: suggestive evidence for a bipolar contribution

BACKGROUND

Highly recurrent major depressive disorder (MDD) has reportedly increased risk of shifting to bipolar disorder; high recurrence frequency has, therefore, featured as evidence of 'soft bipolarity'. We aimed to investigate the genetic underpinnings of total depressive episode count in recurrent MDD.

METHODS

Our primary sample included 1966 MDD cases with negative family history of bipolar disorder from the RADIANT studies. Total episode count was adjusted for gender, age, MDD duration, study and center before being tested for association with genotype in two separate genome-wide analyses (GWAS), in the full set and in a subset of 1364 cases with positive family history of MDD (FH+). We also calculated polygenic scores from the Psychiatric Genomics Consortium MDD and bipolar disorder studies.

RESULTS

Episodicity (especially intermediate episode counts) was an independent index of MDD familial aggregation, replicating previous reports. The GWAS produced no genome-wide significant findings. The strongest signals were detected in the full set at MAGI1 (p=5.1×10(-7)), previously associated with bipolar disorder, and in the FH+ subset at STIM1 (p=3.9×10(-6) after imputation), a calcium channel signaling gene. However, these findings failed to replicate in an independent Munich cohort. In the full set polygenic profile analyses, MDD polygenes predicted episodicity better than bipolar polygenes; however, in the FH+ subset, both polygenic scores performed similarly.

LIMITATIONS

Episode count was self-reported and, therefore, subject to recall bias.

CONCLUSIONS

Our findings lend preliminary support to the hypothesis that highly recurrent MDD with FH+ is part of a 'soft bipolar spectrum' but await replication in larger cohorts.

Age at onset and latency to treatment (duration of untreated illness) in patients with mood and anxiety disorders: a naturalistic study

This study was designed to investigate and compare demographic and clinical features with specific emphasis on age at onset, age at first treatment and, in particular, on duration of untreated illness (DUI), in patients with different mood and anxiety disorders. Study sample included 729 outpatients with the following diagnoses: major depressive disorder (n=181), bipolar disorder type I (BD I, n=115) and II (BD II, n=186), generalized anxiety disorder (n=100), panic disorder (n=96), and obsessive-compulsive disorder (n=51). Main demographic and clinical variables of the sample were compared among the diagnostic groups using one-way analysis of variance or chi tests. The diagnostic groups showed significant differences in relation to age at onset and age at first pharmacological treatment and in relation to latency to treatment. In particular, patients with major depressive disorder showed the shortest DUI (39.08 months), whereas patient with BD II showed the longest DUI (97.2 months) in comparison with the other groups. Within the group with anxiety disorders (F=7.512, P<0.001), patients with panic disorder showed the shortest DUI (44.35 months), whereas patients with obsessive-compulsive disorder showed the longest DUI (90.57 months). The present findings suggest that patients with different mood and anxiety disorders show significant differences in terms of age at onset, age at first treatment and, consequently, DUI, which potentially reflect different reasons influencing treatment delay.