Residual symptoms in elderly major depression remitters

The characteristics of anhedonia in depression: a review from a clinically oriented perspective

Anhedonia, as one of the core symptoms of major depressive disorder (MDD), has been regarded as a potential endophenotype of the disease. Multiple studies have evaluated the potential mechanisms of anhedonia in MDD, and found that MDD patients with anhedonia showed different functions in clinical features. In this review, we focus on the clinical research to explore the differences between MDD patients with and without anhedonia in the clinical manifestations and biological alterations, and elaborate the treatments and prognosis of anhedonia. It is demonstrated that anhedonia is associated with adverse outcomes including more severe depressive episode and suicidality, and poor prognosis in patients with MDD. At the biological level, MDD patients with anhedonia seem to present higher levels of inflammatory factors, abnormal metabolic function and hypermetabolism of BDNF. In brain imaging studies, there are some structural and/ or functional changes in multiple brain regions of subcortical and cortical areas, as well as the limbic system in MDD patients with anhedonia. Meanwhile, preliminary research findings have also indicated that there are associations between intestinal flora imbalance and anhedonia. Moreover, evidence indicated the benefit of some selective serotonin reuptake inhibitors seemed limited on anhedonia, and other treatments including psychotherapy, physical therapy and probiotic interventions has remained to be explored but has interesting potential. Therefore, increased awareness of the anhedonic symptoms and the unique clinical features would benefit improved early diagnosis and therapeutic effects in MDD.

Predictors for quality of life among older adults with depressive disorders: A prospective 3-month follow-up cohort study

PURPOSE

The study aimed to investigate the predictive factors for quality of life among subjects with late-life depression.

DESIGN AND METHODS

Data including depressive symptoms assessed by the Hamilton Rating Scale of Depression (HAMD), geriatric depression scale (GDS), perceived stress scale (PSS), multidimensional scale for perceived social support, and the EQ-5D scale were collected at baseline and at 3-month follow-up from 264 participants.

FINDINGS

After controlling for covariates, time, GDS, PSS, HAMD, and living alone were confirmed predictors for change of EQ-5D scores.

PRACTICE IMPLICATIONS

Perceived stress is important, and intervention to reduce stress especially in early treatment of depressive disorder should be encouraged.

Association between residual symptoms and social functioning in patients with depression

OBJECTIVE

There is a lack of data about residual symptoms in Chinese patients with depression. The aim of this study was to evaluate the association of residual symptoms with social functional impairment in these patients.

METHODS

This was a multicenter cross-sectional study conducted in 11 hospitals in eight cities of China from September 2014 to April 2015. Residual symptoms and social functioning were assessed using the SDS, QIDS-SR16, Q-LES-Q-SF, and PHQ-15 scales. Logistic regression analysis was used to determine the factors associated with social functional impairment.

RESULTS

Among the 1503 patients, 915 (60.9%) had no functional impairment (SDS ≤6) and 588 (39.1%) showed functional impairment (SDS >6). Those with impairment had higher PHQ-15 scores (7.4 ± 4.8 vs. 4.0 ± 3.4, P < 0.0001), lower Q-LES-Q-SF scores (all items P < 0.0001), higher SDS scores (13.9 ± 5.7 vs. 2.8 ± 2.2, P < 0.0001), and higher scores for all QIDS dimensions (all P < .0001). The factors related to functional impairment included QIDS dimension 7 (loss of interest) (OR = 2.137, 95%CI 1.600-2.853, P < 0.0001), QIDS dimension 9 (mental anxiety) (OR = 1.627, 95%CI 1.215-2.180, P = 0.0011), QIDS dimension 3 (appetite) (OR = 1.502, 95%CI 1.141-1.977, P = 0.0037), QIDS dimension 8 (energy) (OR = 1.468, 95%CI 1.092-1.973, P = 0.0110), age (OR = 0.982, 95%CI 0.971-0.993, P = 0.0013), disease course (OR = -1.004, 95%CI 1.002-1.006, P = 0.0004), and QIDS dimension 1 (sleep disorders) (OR = 1.622, 95%CI 1.068-2.463, P = 0.0232).

CONCLUSION

Compared with patients with normal social function, cases with impaired social function have more physical symptoms, more residual symptoms of depression, and less satisfaction with the quality of life. Residual symptoms are associated with social functional impairment in patients with depression.

Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review

BACKGROUND

The adverse effects of loneliness and of poor perceived social support on physical health and mortality are established, but no systematic synthesis is available of their relationship with the outcomes of mental health problems over time. In this systematic review, we aim to examine the evidence on whether loneliness and closely related concepts predict poor outcomes among adults with mental health problems.

METHODS

We searched six databases and reference lists for longitudinal quantitative studies that examined the relationship between baseline measures of loneliness and poor perceived social support and outcomes at follow up. Thirty-four eligible papers were retrieved. Due to heterogeneity among included studies in clinical populations, predictor measures and outcomes, a narrative synthesis was conducted.

RESULTS

We found substantial evidence from prospective studies that people with depression who perceive their social support as poorer have worse outcomes in terms of symptoms, recovery and social functioning. Loneliness has been investigated much less than perceived social support, but there is some evidence that greater loneliness predicts poorer depression outcome. There is also some preliminary evidence of associations between perceived social support and outcomes in schizophrenia, bipolar disorder and anxiety disorders.

CONCLUSIONS

Loneliness and quality of social support in depression are potential targets for development and testing of interventions, while for other conditions further evidence is needed regarding relationships with outcomes.

Effect of Korean Red Ginseng as an adjuvant treatment for women with residual symptoms of major depression

INTRODUCTION

Around 20% of patients with major depression experience residual symptoms. Ginseng has shown potential antidepressant effects in some animal studies and in patients with stress-related somatic symptoms. Therefore, we investigated the effectiveness and tolerability of Korean Red Ginseng adjuvant treatment in patients with residual symptoms of major depression.

METHODS

In this eight-week prospective study, 35 female outpatients aging from 18 to 65 years (45.1 ± 9.5), who were remitted from major depression with residual symptoms, were given Korean Red Ginseng at doses of 3 g/day. The Depression Residual Symptom Scale (DRSS) and Montgomery-Åsberg Depression Rating Scale (MADRS) were administrated to evaluate depressive symptoms. The general severity of symptoms was assessed by a clinician using the Clinical Global Impressions Scale for Severity (CGI-S). The Depression and Somatic Symptom Scale (DSSS) was also used to evaluate somatic symptoms in the subjects. This trial is registered at Clinical.gov, number NCT01496248.

RESULTS

Subjects reported significant decrease in depressive symptoms on the DRSS (P < 0.05) and MADRS (P < 0.01) decreased significantly over the eight-week period. The scores on the CGI-S, an objective measurement of symptoms, showed significant improvement in the severity of illness (P < 0.001). Somatic symptoms on the DSSS also attenuated significantly during the study period (P < 0.05).

DISCUSSION

These results suggest that Korean Red Ginseng is efficacious as an adjuvant treatment for patients experiencing residual symptoms of major depression. Future placebo-controlled research is required to confirm our results.

Functional impairment in patients with major depression in clinical remission: results from the VIVAL-D-Rem, a nationwide, naturalistic, cross-sectional survey

In recent years, the standard for successful treatment of major depression has switched from response to remission; however, little is known about patients who have achieved remission, but still have some residual symptoms and whether they regain previous levels of functioning. In a large, nationwide, cross-sectional, naturalistic survey (VIVAL-D) of 907 patients with major depression treated with a new course of an antidepressant in 41 Italian community psychiatric centers, patients with a Hamilton Rating Scale for Depression, 17-item version (HAM-D17) score up to 14 were selected (n=499). Of these, 169 were considered to be in remission (HAM-D17 ≤ 7) and the other 330 to be mildly depressed. Their level of functioning was evaluated using the SF-12. Only a few (3%) patients in remission were completely symptom free; most were affected by residual symptoms. Patients in remission had better SF-12 scores than those with mild depression, but their functioning was significantly worse than general population norms. In the logistic regression analysis, the HAM-D17 total score and individual items were predictive of poor functioning. Analysis of sensitivity and specificity values showed that a lower cut-off score (4/5) of the HAM-D17 scale was best for predicting poor performance so that a reconsideration of the usual cut-off for remission of 7/8 for HAM-D17 seems overdue.

Factors affecting early attrition and later treatment course of antidepressant treatment of depression in naturalistic settings: an 18-month nationwide population-based study

BACKGROUND

Early attrition can impede treatment success of depression; its contributing factors and impacts on subsequent treatment course need further clarification.

METHODS

All Taiwanese adult patients prescribed with antidepressants for depression (n=216,557) in 2003 were identified through a total population health insurance claims database; their initial contact patterns could be classified into three types of attrition: non-attrition, returning attrition and non-returning attrition. Demographic and clinical characteristics associated with each attrition type were described and relationships between attrition type and subsequent treatment course over an 18-month follow-up period were examined with these demographic/clinical confounders being controlled for.

RESULTS

41.6% of Study subjects had early attrition; among them, 35.3% returned to treatment later. Type of depression, medical/psychiatric comorbidities, painful physical symptoms and past treatment history, as well as prescribing physician specialty and choice of antidepressants, were associated with early attrition. Three types of follow-up pattern over the 18-month follow-up period were identified: sustained treatment-free, continuous treatment and late re-contacts. Patients remaining engaged with treatment within the first three months had higher odds of achieving sustained treatment-free (OR=1.21; 99% CI: 1.16, 1.27) and lower odds of having late re-contacts (OR=0.20; 99% CI: 0.19, 0.21) over the 18-month period, compared to those who returned after early attrition.

CONCLUSIONS

Early attrition is a significant barrier for depression treatment in daily clinical practice and has negative impacts on later treatment course and/or outcome. Early attrition needs to be minimized through shared decision-making, exchange of treatment preferences and proper patient-physician communication.

Clinical differences between early and late remission in depressive patients

OBJECTIVE

Predicting treatment outcome at an early stage is clinically relevant. The main objectives are: to compare rates of remission after acute and continuation phase treatment and to determine the most common residual symptoms among remitted patients; to compare the residual symptoms in early and late remitted and to identify factors that predict early or faster remission.

METHOD

It is a prospective, naturalistic, multicenter, and nationwide epidemiological study of 1595 depressive outpatients. Severity of depressive symptoms was assessed with the Hamilton Depression Rating Scale (HDRS) and the Self Rated Inventory of Depressive Symptomatology (IDS-SR(30)). Assessments were carried out after 6-8 weeks of antidepressant treatment and after 14-20 weeks of continuation treatment. Early remitters were defined with an IDS-SR(30) score ≤ 14 at first and second assessment. Late remitters were defined as those scoring IDS-SR(30) >14 at first and IDS-SR(30) score ≤ 14 at second assessment.

RESULTS

140 subjects (8.8%) were in remission after 6-8 weeks of antidepressant treatment and 862 remitted (59%) after 16-20 weeks of treatment. The mean number of residual symptoms is significantly higher among patients who remit later. Greater differences between early and late remitters were found in the following symptoms: feeling sad, reactivity of mood, interpersonal sensitivity and pleasure/enjoyment. Multivariate analysis showed that only comorbid anxiety disorder is significantly associated with late remission.

CONCLUSIONS

Early remitted patients have a better "quality" of remission. Late remission is associated with residual symptoms more related to core depressive symptoms. Residual symptoms in early remitted patients may constitute a new target for the treatment of depression.

The Impact of Residual Symptoms in Major Depression

The current definition of remission from major depressive disorder does not fully take into account all aspects of patient recovery. Residual symptoms of depression are very common in patients who are classified as being in remission. Patients with residual symptoms are at increased risk of functional and interpersonal impairments, and are at high risk for recurrence of depression. This article discusses the incidence of residual symptoms of depression, as well as the risks and consequences of these symptoms, and will review the state of current treatment.

Partial remission, residual symptoms, and relapse in depression

Partial remission from depression, with residual symptoms, is an important problem in depression. This paper reviews the frequency and features of this outcome, and its association with relapse. Residual symptoms occur in many depressed patients after acute treatment. They span the typical symptoms of depression, except those characteristic of severe disorders. Other persistent abnormalities include social dysfunction, dysfunctional attitudes, hypothalamic-pituitary-adrenal axis overactivity, shortened REM sleep latency, and mood lowering after tryptophan depletion. Associations of some of these with residual symptoms are not clear. There is growing evidence for similar residual symptoms in bipolar disorder, particularly bipolar depression. The most important consequence of residual symptoms is a much-increased risk of relapse, particularly in the first year. Residual symptoms are a strong indication for vigorous and longer than usual continuation of antidepressant treatment in order to prevent relapse. There is good evidence for the use of cognitive therapy as an adjunct.

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.

Outcomes in major depressive disorder: the evolving concept of remission and its implications for treatment

It is increasingly recognised that major depressive disorder can be a chronic condition with many patients experiencing recurrent episodes. Remission from a depressive episode implies the absence or near absence of depressive symptoms. However, for many patients the periods between depressive episodes are not symptom free. Residual symptoms are predictors of relapse or recurrence, and may be associated with residual psychosocial impairment. In clinical studies, remission is commonly defined using a cut-off score on a rating scale for depressive symptoms, such as a score of < or = 7 on the 17-item Hamilton scale. However, there is debate about which scales and cut-offs are optimal and full-length rating scales are not widely used in clinical practice. In spite of such issues, it seems clear that a therapy should aim at the most complete remission possible. Unfortunately, recent studies have highlighted that in clinical practice usually only a low rate of remission is achieved. Although long-term treatment with antidepressants can reduce the risk of relapse or recurrence only a minority of patients in clinical practice achieve this as treatment is often prematurely stopped due to long-term side effects such as sleep disturbance, sexual dysfunctioning and weight gain. Therefore, it represents an unmet need to come up with antidepressant drugs of greater efficacy and improved tolerability as such treatments could lead to more complete remission in more patients.

Residual symptoms in older patients treated for major depression

OBJECTIVE

The purpose of this study was to identify residual symptoms in a sample of older adults treated for major depression and compare individual symptoms present at baseline with those at three months by remission status.

METHODS

The sample was comprised of 229 patients with DSM-IV major depression who were participants in the NIMH Mental Health Clinical Research Center at Duke University. Symptoms were measured using the Montgomery-Asberg Depression Rating Scale (MADRS).

RESULTS

At three months, 86 patients (37.6%) had remitted, or had a MADRS score less than or equal to 9. In the remitted group, the most frequently reported symptoms at three months were inner tension and lassitude. Among nonremitters, the most frequently reported symptoms were reported and apparent sadness, as well as lassitude and inner tension. In the sample as a whole, the symptoms most likely to be present at baseline but not three months were pessimistic and suicidal thoughts, while the most frequently reported emergent symptoms were reduced appetite and inner tension. Patients were much more likely to no longer have a particular symptom than to acquire a new symptom. Overall, the symptoms present at three months were not severe in either group.

CONCLUSIONS

In older adults treated for major depression, residual symptoms at three months may include emergent symptoms as well as persistent symptoms, and are likely to include symptoms of anxiety as well as sadness. These findings have clinical implications for the treatment of late-life depression.

The potential relationship between levels of perceived stress and subtypes of major depressive disorder (MDD)

OBJECTIVE

We wanted to explore whether major depressive disorder (MDD) subtypes (melancholic depression, atypical depression, double depression, and MDD with anger attacks) were related to levels of perceived stress, as measured by the Perceived Stress Scale (PSS).

METHOD

Our sample [n = 298; female = 163 (55%); mean age 40.1 +/- 10.5 years] consisted of out-patients with MDD. The Structured Clinical Interview for DSM-III-R, the 17-item Hamilton Rating Scale for Depression, the Anger Attack Questionnaire, and the PSS were administered prior to initiating treatment.

RESULTS

Depressed women had significantly higher levels of perceived stress (P = 0.02) than depressed men. Greater severity of depression at baseline was significantly related to higher levels of perceived stress (P < 0.0001). After adjusting for age, gender, and severity of depression at baseline, higher levels of perceived stress were significantly related to the presence of anger attacks (P < 0.0001; t = -4.103) as well as to atypical depression (P = 0.0013; t = 3.26).

CONCLUSION

Out-patients with MDD who are more irritable and/or present with atypical features have higher levels of perceived stress, indicating a potential reactive component to their depression.