Social adjustment in depressed patients treated with venlafaxine and amitriptyline

Recent advancements in tension-type headache: a narrative review

INTRODUCTION

Tension-type headache (TTH) is the most common primary headache disorder with a prevalence of up to 78% in general population and huge expenses in terms of health service. Despite its high incidence and impact on life's quality the knowledge on the pathophysiology and efficacious treatment of TTH was still limited.

AREAS COVERED

In recent years, a series of studies highlighted the heterogeneous nature of this pathology that seems to be determined by a complex interaction between genetic, environmental, and neuromuscular factors, which result in nociceptive system activation. In this setting, alongside the simple analgesic therapies used during the acute attack, a series of therapeutic options based on newly acquired experiences have taken hold.

EXPERT REVIEW

Not having a single substrate or a typical site of pathophysiology, TTH must be analyzed in a global and multidisciplinary way. Herein, we perform a narrative review of the most recent advancement stimulating the concept of this disease as the tip of the iceberg of a more complex individual malaise secondary to different alterations. Strategies based solely on symptomatic drugs should therefore be avoided by experienced personnel and treatment should aim at taking charge of the patient considering the processes behind this complex pathology.

The Relationship between Symptom Relief and Psychosocial Functional Improvement during Acute Electroconvulsive Therapy for Patients with Major Depressive Disorder

Background

We aimed to compare the degree of symptom relief to psychosocial functional (abbreviated as "functional") improvement and explore the relationships between symptom relief and functional improvement during acute electroconvulsive therapy for patients with major depressive disorder.

Methods

Major depressive disorder inpatients (n=130) requiring electroconvulsive therapy were recruited. Electroconvulsive therapy was generally performed for a maximum of 12 treatments. Symptom severity, using the 17-item Hamilton Depression Rating Scale, and psychosocial functioning (abbreviated as "functioning"), using the Modified Work and Social Adjustment Scale, were assessed before electroconvulsive therapy, after every 3 electroconvulsive therapy treatments, and after the final electroconvulsive therapy. Both 17-item Hamilton Depression Rating Scale and Modified Work and Social Adjustment Scale scores were converted to T-score units to compare the degrees of changes between depressive symptoms and functioning after electroconvulsive therapy. Structural equation modeling was used to test the relationships between 17-item Hamilton Depression Rating Scale and Modified Work and Social Adjustment Scale during acute electroconvulsive therapy.

Results

One hundred sixteen patients who completed at least the first 3 electroconvulsive therapy treatments entered the analysis. Reduction of 17-item Hamilton Depression Rating Scale T-scores was significantly greater than that of Modified Work and Social Adjustment Scale T-scores at assessments 2, 3, 4, and 5. The model analyzed by structural equation modeling satisfied all indices of goodness-of-fit (chi-square = 32.882, P =.107, TLI = 0.92, CFI = 0.984, RMSEA = 0.057). The 17-item Hamilton Depression Rating Scale change did not predict subsequent Modified Work and Social Adjustment Scale change.

Conclusions

Functioning improved less than depressive symptoms during acute electroconvulsive therapy. Symptom reduction did not predict subsequent functional improvement. Depressive symptoms and functional impairment are distinct domains and should be assessed independently to accurately reflect the effectiveness of electroconvulsive therapy.

Factors Related to the Changes in Quality of Life for Patients With Depression After an Acute Course of Electroconvulsive Therapy

OBJECTIVE

The aim of this study was to examine the effect of electroconvulsive therapy (ECT) on quality of life (QOL), depressive symptoms, and functioning for patients with depression, and to explore the variables related to QOL changes.

METHODS

Ninety-five inpatients with depression receiving at least 6 ECT sessions and completed all measures were included. Quality of life, symptom severity, and functioning were assessed using Short Form 36 (SF-36), the 17-item Hamilton Rating Scale for Depression (HAMD-17), and the Modified Work and Social Adjustment Scale (MWSAS), before and after ECT. The SF-36 includes 8 subscales, physical component summary (PCS), and mental component summary (MCS). Adverse effects after ECT, including headache, muscle pain, and nausea/vomiting, were also recorded.

RESULTS

All 8 SF-36 subscales, PCS, MCS, HAMD-17, and MWSAS improved significantly after treatment. Using multiple linear regression analysis, MWSAS changes predicted PCS changes significantly after adjusting for baseline PCS. Similarly, using multiple linear regression analysis, MWSAS changes were significant variables associated with MCS changes after adjusting for ECT frequency, HAMD-17 changes, and baseline MCS. The ECT improved QOL, depressive symptoms, and functioning.

CONCLUSIONS

Whether strategies to enhance functioning during an acute course of ECT could improve QOL is needed to be examined in a further study.

Restoring function in major depressive disorder: A systematic review

BACKGROUND

Functional impairment contributes to significant disability and economic burden in major depressive disorder (MDD). Treatment response is measured by improvement in depressive symptoms, but functional improvement often lags behind symptomatic improvement. Residual deficits are associated with relapse of depressive symptoms.

METHODS

A literature search was conducted using the following terms: "major depressive disorder," "functional impairment," "functional outcomes," "recovery of function," "treatment outcome," "outcome assessment," "social functioning," "presenteeism," "absenteeism," "psychiatric status rating scales," and "quality of life." Search limits included publication date (January 1, 1995 to August 31, 2016), English language, and human clinical trials. Controlled, acute-phase, nonrecurrent MDD treatment studies in adults were included if a functional outcome was measured at baseline and endpoint.

RESULTS

The qualitative analysis included 35 controlled studies. The Sheehan Disability Scale was the most commonly used functional assessment. Antidepressant treatments significantly improved functional outcomes. Early treatment response predicted functional improvement, while baseline disease severity did not.

LIMITATIONS

Clinical studies utilized various methodologies and assessments for functional impairment, and were not standardized or adequately powered.

CONCLUSIONS

The lack of synchronicity between symptomatic and functional improvement highlights an unmet need for MDD. Treatment guided by routine monitoring of symptoms and functionality may minimize residual functional impairments.

A Randomized, Double-Blind, Placebo-Controlled Study of Venlafaxine XR in Out-Patients With Tension-Type Headache

The aim of this study was to evaluate in a double-blind, randomized, placebo-controlled study the safety and efficacy of venlafaxine extended release (XR) in the prophylactic treatment of out-patients with tension-type headache (TTH) and no current depression or anxiety disorders. Sixty neurology and headache clinic out-patients meeting the International Headache Society diagnostic criteria for TTH were treated with venlafaxine XR (150 mg/day, n = 34) or placebo ( n = 26) for 12 weeks. The primary efficacy variable was the decline in number of days with headache. At end-point, the venlafaxine XR group had a significantly greater decrease in the number of days with headache compared with placebo ( P = 0.05). Differences with regard to secondary efficacy variables where not significant. The number needed to treat for responders (≥50% reduction in days with headache) was 3.48. Six patients in the venlafaxine XR group interrupted therapy due to adverse events, while no patients in the placebo group did so for the same reason. The number needed to harm was 5.58. This study provides preliminary evidence for the efficacy and safety of venlafaxine XR 150 mg/day in reducing the number of days with TTH.

The Effects of Newer Antidepressants on Occupational Impairment in Major Depressive Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

A substantial proportion of the disease burden of major depressive disorder (MDD) results from impairments in occupational functioning, including disability and reduced productivity. Accumulating evidence suggests that antidepressants can improve functional as well as symptomatic outcomes in patients with MDD. We examined the treatment effects of newer antidepressants on occupational impairment in MDD, based on a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched MEDLINE, EMBASE, and ClinicalTrials.gov for the period 1 January 1992 to 15 June 2015 to identify RCTs of newer antidepressants (excluding tricyclic antidepressants and monoamine oxidase inhibitors), with or without a placebo condition, that included a validated measure of occupational functioning in patients with MDD. Abstracts were scanned for eligibility by two independent reviewers and investigators of unpublished studies were contacted to obtain data. Study data were extracted and double-entered for accuracy. We selected the Sheehan Disability Scale Work/School subscale (SDS-Work) for the meta-analysis because it was the most consistently used assessment of occupational impairment. Analysis employed a random-effects model.

RESULTS

The systematic review initially identified 42 RCTs but only 28 (67 %) had data on occupational outcomes that were published or obtained from investigators. The SDS-Work subscale was used in 25 of 28 trials; five other assessments of occupational functioning were used in seven trials. Data were synthesized from 17 placebo-controlled studies (n = 7031) that used the SDS-Work subscale. Antidepressants (n = 4722) were significantly superior to placebo (n = 2309) in improving SDS-Work scores at 8 weeks, with a mean difference of 0.73 [95 % confidence interval (CI) 0.60-0.86] and a standardized mean difference of 0.28 (95 % CI 0.23-0.33), representing small effects.

LIMITATIONS

Few included trials reported on the employment status of their samples, and most trials were of short-term treatment duration (8-12 weeks). Several RCTs that collected data on occupational outcomes were also excluded from the review and meta-analysis because their data were unpublished and unobtainable.

CONCLUSIONS

Our meta-analysis suggests that newer antidepressants have a small, positive impact on occupational impairment in the short-term, but the clinical significance of this impact is questionable. To improve assessment of this important outcome, future research studies should use more comprehensive measures of occupational functioning, productivity and impairment, and longer treatment durations.

The relationship between symptom relief and functional improvement during acute fluoxetine treatment for patients with major depressive disorder

BACKGROUND

The purpose of this study was to compare the rate of symptom relief to functional improvement and examine the relationships between symptom relief and functional improvement during the acute phase of treatment.

METHODS

A total of 131 acutely ill inpatients with major depressive disorder were enrolled to receive 20mg of fluoxetine daily for 6 weeks. Symptom severity, using the 17-item Hamilton Depression Rating Scale (HAMD-17), and functioning, using the Modified Work and Social Adjustment Scale (MWSAS), were measured regularly. The outcome measures were the HAMD-17 score and MWSAS score at weeks 1, 2, 3, 4, and 6. We compared the effect size and the reduction rate of HAMD-17 to those of MWSAS at week 1, 2, 3, 4, and 6. Structural equation modeling was used to examine relationships among the study variables.

RESULTS

Of the 131 participants, 126 had at least one post-baseline assessment at week 1 and were included in the analysis. The HAMD-17 had a larger effect size and reduction rate than the MWSAS at weeks 1, 2, 3, 4, and 6. Parsimonious model satisfied all indices of goodness-of-fit (Chi-Square/df=1.479, TLI=0.978, CFI=0.986, RMSEA=0.062) and had all paths with significant path coefficients. MWSAS at week 0 predicted HAMD-17 at week 1.

LIMITATION

This was an open-labeled study with small sample size.

CONCLUSION

Depressive symptoms improved more quickly than functioning during the acute phase of treatment. Depressive symptoms and functional impairment are distinct domains, and should be assessed independently.

Change in psychosocial functioning and depressive symptoms during acute-phase cognitive therapy for depression

BACKGROUND

Major depressive disorder (MDD) is highly prevalent, is recurrent, and impairs people's work, relationships and leisure. Acute-phase treatments improve psychosocial impairment associated with MDD, but how these improvements occur is unclear. In this study, we tested the hypotheses that reductions in depressive symptoms exceed, precede and predict improvements in psychosocial functioning.

METHOD

Patients with recurrent MDD (n=523; 68% women, 81% Caucasian, mean age 42 years) received acute-phase cognitive therapy (CT). We measured functioning and symptom severity with the Social Adjustment Scale - Self-Report (SAS-SR), Range of Impaired Functioning Tool (RIFT), Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HAMD) and Inventory for Depressive Symptomatology - Self-Report (IDS-SR). We tested cross-lagged correlations between functioning and symptoms measured at baseline and the beginning, middle and end of acute-phase CT.

RESULTS

Pre- to post-treatment improvement in psychosocial functioning and depressive symptoms was large and intercorrelated. Depressive symptoms improved more and sooner than did psychosocial functioning. However, among four assessments across the course of treatment, improvements in functioning more strongly predicted later improvement in symptoms than vice versa.

CONCLUSIONS

Improvements in psychosocial functioning and depressive symptoms correlate substantially during acute-phase CT, and improvements in functioning may play a role in subsequent symptom reduction during acute-phase CT.

Improvement of the noradrenergic symptom cluster following treatment with milnacipran

Depression has a major impact on social functioning. Decreased concentration, mental and physical slowing, loss of energy, lassitude, tiredness, and reduced self-care are all symptoms related to reduced noradrenergic activity. Depressed mood; loss of interest or pleasure; sleep disturbances; and feelings of worthlessness, pessimism, and anxiety are related to reduced activity of both serotonergic and noradrenergic neurotransmission. The importance of noradrenergic neurotransmission in social functioning is supported by studies with the specific norepinephrine reuptake inhibitor reboxetine. In healthy volunteers, reboxetine increases cooperative social behavior and social drive. A placebo-controlled study in depressed patients comparing reboxetine with the selective serotonin reuptake inhibitor (SSRI) fluoxetine showed significantly greater improvement in social adaptation with reboxetine. Two recent studies have examined the effect of the serotonin and norepinephrine reuptake inhibitor milnacipran on social adaptation. A study in depressed patients found that at the end of 8 weeks of treatment with milnacipran, 42.2% patients were in remission on the Social Adaptation Self-evaluation Scale (SASS). Another study in depressed workers or homemakers found that mean depression scores were significantly reduced after 2 weeks, whereas the SASS scores were significantly improved after 4 weeks. A preliminary study comparing depressed patients treated with milnacipran or the SSRI paroxetine showed that milnacipran treatment resulted in a greater number of patients in social remission. The available data thus suggest that milnacipran may improve social functioning, with a possibly greater effect than the SSRI paroxetine. These preliminary data suggest further evaluation of social dysfunction and its treatment outcome in future trials of milnacipran.

Improvement of social adaptation in depression with serotonin and norepinephrine reuptake inhibitors

Depression is a disabling condition resulting in significant impairment in social functioning, involving the patient's family, friends, work colleagues, and society at large. Although both psychologic and pharmacologic treatments generally improve many depressive symptoms, they do not always result in significant improvement in social functioning. The importance of recovery of social functioning in depressed patients is now widely appreciated, and studies are beginning to include it in evaluations of therapeutic efficacy. Among the various social adjustment evaluation rating scales, the Social Adaptation Self-Evaluation Scale, a social motivation and behavior scale, has been found to be simple to use and sensitive to change. Using this scale, the selective norepinephrine reuptake inhibitor, reboxetine, has been shown to be significantly more effective in improving social functioning than the selective serotonin reuptake inhibitor, fluoxetine. These findings are consistent with the notion that improvement in social adaptation involves functions depending primarily on noradrenergic neurotransmission. This hypothesis suggests that the serotonin and norepinephrine reuptake inhibitors, venlafaxine, duloxetine, and milnacipran, could be particularly helpful in improving social functioning. Preliminary studies with the serotonin and norepinephrine reuptake inhibitors suggest that they significantly improve social functioning. Comparative studies with selective serotonin reuptake inhibitors on the effects on social functioning should be encouraged.

Event-related functional magnetic resonance imaging measures of neural activity to positive social stimuli in pre- and post-treatment depression

BACKGROUND

Relationships between aberrant social functioning and depression have been explored via behavioral, clinical, and survey methodologies, highlighting their importance in the etiology of depression. The neural underpinnings of these relationships, however, have not been explored.

METHODS

Nine depressed participants and 14 never-depressed control subjects viewed emotional and neutral pictures at two functional magnetic resonance imaging (fMRI) scanning sessions approximately 22 weeks apart. In the interim, depressed patients received the antidepressant Venlafaxine. Positively rated images were parsed into three separate comparisons: social interaction, human faces, and sexual images; across scanning session, activation to these images was compared with other positively rated images.

RESULTS

For each of the three social stimulus types (social interaction, faces, sexual images), a distinguishable circuitry was activated equally in non-depressed control subjects and post-treatment depressed subjects but showed a hypo-response in the depressed group pre-treatment. These structures include regions of prefrontal, temporal, and parietal cortices, insula, basal ganglia, and the hippocampus.

CONCLUSIONS

The neural hypo-response to positively valenced social stimuli that is observed in depression remits as response to antidepressant medication occurs, suggesting a state-dependent deficiency in response to positive social incentives. These findings underscore the importance of addressing social dysfunction in research and treatment of depression.

Reliability, validity and standardization of the Japanese version of the Social Adjustment Scale-Self Report

The purpose of the present paper was to examine the reliability and validity of the Japanese version of the Social Adjustment Scale-Self Report (SAS-SR) and to present its normative data. The SAS-SR was administered to a random sample of all the employees of a large general hospital, together with the General Health Questionnaire (n = 363). It was also administered to a representative subset of first-visit patients at 33 psychiatric hospitals and clinics from all over Japan, along with the semistructured psychiatric interview to ascertain the patients' diagnoses (n = 1581). For the internal consistency reliability of the subscales and the overall scale of the SAS-SR, Cronbach's alpha was between 0.61 and 0.73. The Pearson product-moment correlations between the subscale and overall scale scores with the GHQ score were mostly >0.3. The scores were statistically significantly and substantively different between the normal sample and the patient samples, and were also meaningful, differentiating between various diagnostic subgroups. The reference ranges of the SAS-SR scores for mentally healthy subjects were calculated as 95% prediction intervals; for example, 1.22-2.22 for the overall score. The Japanese version of the SAS-SR has good reliability and satisfactory validity. The present study provided reference ranges for its scores in order to increase their interpretability. With its ease of administration and its rich subscales, the scale promises to offer a psychometrically sound measure with which to assess social adjustment in people with various psychiatric disorders.