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Gonterman F. A Systematic Review Assessing Patient-Related Predictors of Response to Transcranial Magnetic Stimulation in Major Depressive Disorder. Neuropsychiatr Dis Treat 2023; 19:565-577. [PMID: 36919097 PMCID: PMC10008378 DOI: 10.2147/ndt.s388164] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Objective The safety and efficacy of transcranial magnetic stimulation (TMS) in the acute treatment of major depressive disorder (MDD) is well established. However, it is not well understood which patient-related factors are associated with a more robust antidepressant response. Identifying predictive factors for therapeutic response to TMS treatment in depression will guide clinicians in patient selection. Methods By systematic review of clinical trial data, the current study aims to identify and analyze reported patient-specific predictors of response to an acute course of TMS treatment for MDD. PubMed was searched for randomized controlled trials of TMS for patients with depression. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results TMS data were available from 375 studies, 18 of which were included in this review. Treatment response is inversely associated with treatment refractoriness and age. Conclusion Inadequate sample size and large heterogeneity in study parameters among clinical trials limit any strong conclusions from being drawn; nonetheless, despite these limitations, there is mounting evidence, which points to age and treatment refractoriness as candidate variables for predicting clinical outcome. Implications of these findings for treatment of MDD are discussed.
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Affiliation(s)
- Fernando Gonterman
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Counseling & Clinical Psychology, Teachers College Columbia University, New York, NY, USA
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Kim HK, Blumberger DM, Karp JF, Lenze E, Reynolds CF, Mulsant BH. Venlafaxine XR treatment for older patients with major depressive disorder: decision trees for when to change treatment. EVIDENCE-BASED MENTAL HEALTH 2022; 25:156-162. [PMID: 36100357 PMCID: PMC10134194 DOI: 10.1136/ebmental-2022-300479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/31/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Predictors of antidepressant response in older patients with major depressive disorder (MDD) need to be confirmed before they can guide treatment. OBJECTIVE To create decision trees for early identification of older patients with MDD who are unlikely to respond to 12 weeks of antidepressant treatment, we analysed data from 454 older participants treated with venlafaxine XR (150-300 mg/day) for up to 12 weeks in the Incomplete Response in Late-Life Depression: Getting to Remission study. METHODS We selected the earliest decision point when we could detect participants who had not yet responded (defined as >50% symptom improvement) but would do so after 12 weeks of treatment. Using receiver operating characteristic models, we created two decision trees to minimise either false identification of future responders (false positives) or false identification of future non-responders (false negatives). These decision trees integrated baseline characteristics and treatment response at the early decision point as predictors. FINDING We selected week 4 as the optimal early decision point. Both decision trees shared minimal symptom reduction at week 4, longer episode duration and not having responded to an antidepressant previously as predictors of non-response. Test negative predictive values of the leftmost terminal node of the two trees were 77.4% and 76.6%, respectively. CONCLUSION Our decision trees have the potential to guide treatment in older patients with MDD but they require to be validated in other larger samples. CLINICAL IMPLICATIONS Once confirmed, our findings may be used to guide changes in antidepressant treatment in older patients with poor early response.
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Affiliation(s)
| | - Daniel M Blumberger
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jordan F Karp
- Department of Psychiatry, University of Arizona, Tucson, Arizona, USA
| | - Eric Lenze
- Department of Psychiatry, University of Washington, St. Louis, Missouri, USA
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benoit H Mulsant
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Fuhr K, Werle D, Batra A. How does early symptom change predict subsequent course of depressive symptoms during psychotherapy? Psychol Psychother 2022; 95:137-154. [PMID: 34676660 DOI: 10.1111/papt.12370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Previous studies reported about the influence of early changes on treatment response. However, the question of whether early changes can predict the subsequent course of depressive symptoms during treatment with psychotherapy has not yet been clearly answered. We aimed to investigate whether symptom course in the first weeks at the level of individual session can predict the further symptom progression on a session to session level during psychotherapy treatment in patients with Major Depression (MD). DESIGN Monocentric randomized controlled trial with psychotherapeutic treatment either with cognitive-behavioural therapy (CBT) or hypnotherapy (HT). The longitudinal course of weekly depressive symptoms during the six months treatment period was examined. METHODS In this RCT with 152 randomized patients suffering from current mild-to-moderate MD, depressive symptoms were assessed on a weekly basis during the 20 sessions' treatment with individual psychotherapy. We only included patients for which sufficient data for our analysis were available. Three different linear and quadratic mixed model analyses with random effects for each patient were tested: Early change was defined as the individual percentage symptom change during the first two, three, four and five weeks. Symptoms from session four, five, six and seven onward were predicted using different models, with early change added to the model in a final step. Calculating all models separately for CBT and HT lead to comparable results. RESULT A slow symptom decrease after session four, five, six, seven onward to the end of the treatment was found. However, adding early change to the model, had no effect on the further symptom course in all models. CONCLUSION Symptom changes at early stages of psychotherapy should not be considered as being predictive for further symptom course. PRACTITIONER POINTS The individual early symptom change in a treatment with psychotherapy in the first two, three, four, or five weeks of treatment does not predict the subsequent symptom course from session four, five, six, or seven onward at a session to session level. Symptom changes at early stages of psychotherapy should not be considered as being predictive for further symptom course. We found a symptom reduction ranging from 3% to 16% in the first two, three, four, or five weeks. Treatment response between the first and last therapy session was found in 54.5%, the number of remitted patients (with PHQ-9 scores < 5) was 44.7%. A small symptom improvement of between 0.21 and 0.42 points in the PHQ-9 scores per week in later stages of psychotherapy is likely in all patients (with and without early symptom improvement).
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Affiliation(s)
- Kristina Fuhr
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Germany
| | - Dustin Werle
- Clinical Psychology and Psychotherapy, Department of Psychology, University of Tuebingen, Germany
| | - Anil Batra
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Germany
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Yrondi A, Arbus C, Bennabi D, D’Amato T, Bellivier F, Bougerol T, Camus V, Courtet P, Doumy O, Genty JB, Holtzmann J, Horn M, Lancon C, Leboyer M, Llorca PM, Maruani J, Moirand R, Molière F, Petrucci J, Richieri R, Samalin L, Stephan F, Vaiva G, Walter M, Haffen E, Aouizerate B, El-Hage W. Relationship between childhood physical abuse and clinical severity of treatment-resistant depression in a geriatric population. PLoS One 2021; 16:e0250148. [PMID: 33878137 PMCID: PMC8057608 DOI: 10.1371/journal.pone.0250148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/01/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction We assessed the correlation between childhood maltreatment (CM) and severity of depression in an elderly unipolar Treatment-Resistant Depression (TRD) sample. Methods Patients were enrolled from a longitudinal cohort (FACE-DR) of the French Network of Expert TRD Centres. Results Our sample included 96 patients (33% of the overall cohort) aged 60 years or above, with a mean age of 67.2 (SD = 5.7). The majority of the patients were female (62.5%). The Montgomery and Asberg Depression Rating Scale (MADRS) and Quick Inventory Depression Scale-Self Report (QIDS-SR) mean scores were high, 28.2 (SD = 7.49) [MADRS score range: 0–60; moderate severity≥20, high severity≥35] and 16.5 (SD = 4.94) [IDS-SR score range: 0–27; moderate severity≥11, high severity≥16], respectively. Mean self-esteem scores were 22.47 (SD = 6.26) [range 0–30]. In an age- and sex-adjusted model, we found a positive correlation between childhood trauma (CTQ scores) and depressive symptom severity [MADRS (β = 0.274; p = 0.07) and QIDS-SR (β = 0.302; p = 0.005) scores]. We detected a statistically significant correlation between physical abuse and depressive symptom severity [MADRS (β = 0.304; p = 0.03) and QIDS-SR (β = 0.362; p = 0.005) scores]. We did not observe any significant correlation between other types of trauma and depressive symptom severity. We showed that self-esteem (Rosenberg scale) mediated the effect of physical abuse (PA) on the intensity of depressive symptoms [MADRS: b = 0.318, 95% BCa C.I. [0.07, 0.62]; QIDS-SR: b = 0.177, 95% BCa C.I. [0.04, 0.37]]. Preacher & Kelly’s Kappa Squared values of 19.1% (k2 = 0.191) and 16% (k2 = 0.16), respectively for the two scales, indicate a moderate effect. Conclusion To our knowledge, this is the first study conducted in a geriatric TRD population documenting an association between childhood trauma (mainly relating to PA) and the intensity of depressive symptoms.
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Affiliation(s)
- Antoine Yrondi
- Fondation FondaMental, Creteil, France
- Service de Psychiatrie et de Psychologie Médicale de l’adulte (Department of Psychiatry and Adult Medical Psychology), Centre Expert Dépression Résistante FondaMental (FondaMental Advanced Centre of Expertise in Resistant Depression, CHU de Toulouse (University Hospital Centre), Hôpital Purpan, ToNIC Toulouse NeuroImaging Centre, Université de Toulouse (Toulouse University), INSERM, UPS, Toulouse, France
- * E-mail:
| | - Christophe Arbus
- Fondation FondaMental, Creteil, France
- Service de Psychiatrie et de Psychologie Médicale de l’adulte (Department of Psychiatry and Adult Medical Psychology), Centre Expert Dépression Résistante FondaMental (FondaMental Advanced Centre of Expertise in Resistant Depression, CHU de Toulouse (University Hospital Centre), Hôpital Purpan, ToNIC Toulouse NeuroImaging Centre, Université de Toulouse (Toulouse University), INSERM, UPS, Toulouse, France
| | - Djamila Bennabi
- Fondation FondaMental, Creteil, France
- Service de Psychiatrie, Centre Expert Dépression Résistante FondaMental, CIC-1431 INSERM, CHU de Besançon, Université de Bourgogne Franche Comté, Besançon, France
| | - Thierry D’Amato
- Fondation FondaMental, Creteil, France
- INSERM U1028; CNRS UMR5292; University Lyon 1, Villeurbanne, F-69000, France; Lyon Neuroscience Research Centre; Psychiatric Disorders: From Resistance to Response ΨR2 Team; Centre Hospitalier Le Vinatier (Hospital Centre); Bron, France
| | - Frank Bellivier
- Fondation FondaMental, Creteil, France
- AP-HP, GH Saint-Louis—Lariboisière—Fernand Widal, Pôle Neurosciences Tête et Cou (Head and Neck Neurosciences Cluster), University Paris Diderot, Paris, France
| | - Thierry Bougerol
- Fondation FondaMental, Creteil, France
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences (Institute of Neurosciences), Grenoble, France
| | - Vincent Camus
- Fondation FondaMental, Creteil, France
- U1253, iBrain, CIC1415, Inserm, CHRU de Tours (Regional University Hospital Centre), Université de Tours, Tours, France
| | - Philippe Courtet
- Fondation FondaMental, Creteil, France
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, INSERM U1061, Montpellier University, Montpellier, France
| | - Olivier Doumy
- Fondation FondaMental, Creteil, France
- Pôle de Psychiatrie Générale et Universitaire (General and University Psychiatry Cluster), Centre Expert Dépression Résistante FondaMental, CH Charles Perrens, Bordeaux, Laboratoire Nutrition et Neurobiologie intégrée (Integrated Nutrition and Neurobiology Laboratory) (UMR INRAE 1286), Université de Bordeaux (Bordeaux University), Bordeaux, France
| | - Jean-Baptiste Genty
- Fondation FondaMental, Creteil, France
- Université Paris-Est, UMR_S955, UPEC, Créteil, France Inserm, U955, Equipe 15 Psychiatrie génétique (Team 15 Genetic Psychiatry), Créteil, France AP-HP, Hôpital H. Mondor-A. Chenevier, Pôle de psychiatrie (Psychiatry Cluster), Créteil, France Fondation FondaMental, Fondation de Cooperation Scientifique (Scientific Cooperation Foundation), Créteil, France
| | - Jérôme Holtzmann
- Fondation FondaMental, Creteil, France
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences (Institute of Neurosciences), Grenoble, France
| | - Mathilde Horn
- Fondation FondaMental, Creteil, France
- Service de Psychiatrie adulte (Department of Adult Psychiatry), Centre Expert Dépression Résistante FondaMental, CHRU de Lille, Hôpital Fontan 1, Lille, France
| | - Christophe Lancon
- Fondation FondaMental, Creteil, France
- Pôle Psychiatrie, Centre Expert Dépression Résistante FondaMental, CHU La Conception, Marseille, France
| | - Marion Leboyer
- Fondation FondaMental, Creteil, France
- Université Paris-Est, UMR_S955, UPEC, Créteil, France Inserm, U955, Equipe 15 Psychiatrie génétique (Team 15 Genetic Psychiatry), Créteil, France AP-HP, Hôpital H. Mondor-A. Chenevier, Pôle de psychiatrie (Psychiatry Cluster), Créteil, France Fondation FondaMental, Fondation de Cooperation Scientifique (Scientific Cooperation Foundation), Créteil, France
| | - Pierre-Michel Llorca
- Fondation FondaMental, Creteil, France
- Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | - Julia Maruani
- Fondation FondaMental, Creteil, France
- AP-HP, GH Saint-Louis—Lariboisière—Fernand Widal, Pôle Neurosciences Tête et Cou (Head and Neck Neurosciences Cluster), University Paris Diderot, Paris, France
| | - Rémi Moirand
- Fondation FondaMental, Creteil, France
- INSERM U1028; CNRS UMR5292; University Lyon 1, Villeurbanne, F-69000, France; Lyon Neuroscience Research Centre; Psychiatric Disorders: From Resistance to Response ΨR2 Team; Centre Hospitalier Le Vinatier (Hospital Centre); Bron, France
| | - Fanny Molière
- Fondation FondaMental, Creteil, France
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, INSERM U1061, Montpellier University, Montpellier, France
| | - Jean Petrucci
- Fondation FondaMental, Creteil, France
- Université Paris-Est, UMR_S955, UPEC, Créteil, France Inserm, U955, Equipe 15 Psychiatrie génétique (Team 15 Genetic Psychiatry), Créteil, France AP-HP, Hôpital H. Mondor-A. Chenevier, Pôle de psychiatrie (Psychiatry Cluster), Créteil, France Fondation FondaMental, Fondation de Cooperation Scientifique (Scientific Cooperation Foundation), Créteil, France
| | - Raphaelle Richieri
- Fondation FondaMental, Creteil, France
- Pôle Psychiatrie, Centre Expert Dépression Résistante FondaMental, CHU La Conception, Marseille, France
| | - Ludovic Samalin
- Fondation FondaMental, Creteil, France
- Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | - Florian Stephan
- Fondation FondaMental, Creteil, France
- Service Hospitalo-Universitaire de Psychiatrie Générale et de Réhabilitation Psycho Sociale 29G01 et 29G02 (University Hospital Department of General Psychiatry and Psychosocial Rehabilitation), Centre Expert Depression Résistante FondaMental, CHRU de Brest, Hôpital de Bohars, Brest, France
| | - Guillaume Vaiva
- Fondation FondaMental, Creteil, France
- Centre National de Ressources et Résilience pour les psychotraumatisme (National Resilience and Resources Centre for Psychological Trauma), Lille, France
| | - Michel Walter
- Fondation FondaMental, Creteil, France
- Service Hospitalo-Universitaire de Psychiatrie Générale et de Réhabilitation Psycho Sociale 29G01 et 29G02 (University Hospital Department of General Psychiatry and Psychosocial Rehabilitation), Centre Expert Depression Résistante FondaMental, CHRU de Brest, Hôpital de Bohars, Brest, France
| | | | - Emmanuel Haffen
- Fondation FondaMental, Creteil, France
- Service de Psychiatrie, Centre Expert Dépression Résistante FondaMental, CIC-1431 INSERM, CHU de Besançon, Université de Bourgogne Franche Comté, Besançon, France
| | - Bruno Aouizerate
- Fondation FondaMental, Creteil, France
- Pôle de Psychiatrie Générale et Universitaire (General and University Psychiatry Cluster), Centre Expert Dépression Résistante FondaMental, CH Charles Perrens, Bordeaux, Laboratoire Nutrition et Neurobiologie intégrée (Integrated Nutrition and Neurobiology Laboratory) (UMR INRAE 1286), Université de Bordeaux (Bordeaux University), Bordeaux, France
| | - Wissam El-Hage
- Fondation FondaMental, Creteil, France
- U1253, iBrain, CIC1415, Inserm, CHRU de Tours (Regional University Hospital Centre), Université de Tours, Tours, France
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Lv N, Xiao L, Majd M, Lavori PW, Smyth JM, Rosas LG, Venditti EM, Snowden MB, Lewis MA, Ward E, Lesser L, Williams LM, Azar KMJ, Ma J. Variability in engagement and progress in efficacious integrated collaborative care for primary care patients with obesity and depression: Within-treatment analysis in the RAINBOW trial. PLoS One 2020; 15:e0231743. [PMID: 32315362 PMCID: PMC7173791 DOI: 10.1371/journal.pone.0231743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 03/27/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The RAINBOW randomized clinical trial validated the efficacy of an integrated collaborative care intervention for obesity and depression in primary care, although the effect was modest. To inform intervention optimization, this study investigated within-treatment variability in participant engagement and progress. METHODS Data were collected in 2014-2017 and analyzed post hoc in 2018. Cluster analysis evaluated patterns of change in weekly self-monitored weight from week 6 up to week 52 and depression scores on the Patient Health Questionnaire-9 (PHQ-9) from up to 15 individual sessions during the 12-month intervention. Chi-square tests and ANOVA compared weight loss and depression outcomes objectively measured by blinded assessors to validate differences among categories of treatment engagement and progress defined based on cluster analysis results. RESULTS Among 204 intervention participants (50.9 [SD, 12.2] years, 71% female, 72% non-Hispanic White, BMI 36.7 [6.9], PHQ-9 14.1 [3.2]), 31% (n = 63) had poor engagement, on average completing self-monitored weight in <3 of 46 weeks and <5 of 15 sessions. Among them, 50 (79%) discontinued the intervention by session 6 (week 8). Engaged participants (n = 141; 69%) self-monitored weight for 11-22 weeks, attended almost all 15 sessions, but showed variable treatment progress based on patterns of change in self-monitored weight and PHQ-9 scores over 12 months. Three patterns of weight change (%) represented minimal weight loss (n = 50, linear β1 = -0.06, quadratic β2 = 0.001), moderate weight loss (n = 61, β1 = -0.28, β2 = 0.002), and substantial weight loss (n = 12, β1 = -0.53, β2 = 0.005). Three patterns of change in PHQ-9 scores represented moderate depression without treatment progress (n = 40, intercept β0 = 11.05, β1 = -0.11, β2 = 0.002), moderate depression with treatment progress (n = 20, β0 = 12.90, β1 = -0.42, β2 = 0.006), and milder depression with treatment progress (n = 81, β0 = 7.41, β1 = -0.23, β2 = 0.003). The patterns diverged within 6-8 weeks and persisted throughout the intervention. Objectively measured weight loss and depression outcomes were significantly worse among participants with poor engagement or poor progress on either weight or PHQ-9 than those showing progress on both. CONCLUSIONS Participants demonstrating poor engagement or poor progress could be identified early during the intervention and were more likely to fail treatment at the end of the intervention. This insight could inform individualized and timely optimization to enhance treatment efficacy. TRIAL REGISTRATION ClinicalTrials.gov# NCT02246413.
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Affiliation(s)
- Nan Lv
- Institute of Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Lan Xiao
- Department of Medicine, Stanford University, Palo Alto, California, United States of America
| | - Marzieh Majd
- Department of Biobehavioral Health, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Philip W. Lavori
- Department of Biomedical Data Science, Stanford University, Stanford, California, United States of America
| | - Joshua M. Smyth
- Department of Biobehavioral Health, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Lisa G. Rosas
- Department of Health Research and Policy and Medicine, Stanford University, Palo Alto, California, United States of America
| | - Elizabeth M. Venditti
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Mark B. Snowden
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, United States of America
| | - Megan A. Lewis
- Center for Communications Science, RTI International, Seattle, Washington, United States of America
| | - Elizabeth Ward
- Pacific Coast Psychiatric Associates, San Francisco, California, United States of America
| | - Lenard Lesser
- One Medical, San Francisco, California, United States of America
| | - Leanne M. Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, United States of America
| | - Kristen M. J. Azar
- Sutter Health Research Enterprise, Center for Health Systems Research, Walnut Creek, California, United States of America
| | - Jun Ma
- Institute of Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
- * E-mail:
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Beard JIL, Delgadillo J. Early response to psychological therapy as a predictor of depression and anxiety treatment outcomes: A systematic review and meta-analysis. Depress Anxiety 2019; 36:866-878. [PMID: 31233263 DOI: 10.1002/da.22931] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/10/2019] [Accepted: 05/25/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Previous studies indicate that early symptomatic improvement, typically observed during the first 4 weeks of psychological therapy, is associated with positive treatment outcomes for a range of mental health problems. However, the replicability, statistical significance, and magnitude of this association remain unclear. AIM The current study reviewed the literature on early response to psychological interventions for adults with depression and anxiety symptoms. METHODS A systematic review and random effects meta-analysis were conducted, including studies found in Medline, PsychINFO, SCOPUS, Web of Science, and through reference lists and reverse citations. RESULTS Twenty-five eligible studies including 11,091 patients measured early response and examined associations with posttreatment outcomes. It was possible to extract and/or calculate effect size data from 15 studies to conduct a meta-analysis. A large pooled effect size (g = 0.87 [95% confidence interval: 0.63-1.10], p < .0001) indicated that early responders had significantly better posttreatment outcomes compared to cases without early response, and this effect was larger in anxiety (g = 1.37) compared to depression (g = 0.76) measures. Most studies were of good quality and there was no evidence of publication bias. The main limitations concerned insufficient statistical reporting in some studies, which precluded their inclusion in meta-analysis, and it was not possible to examine effect sizes according to different outcome questionnaires. CONCLUSION There is robust and replicated evidence that early response to therapy is a reliable prognostic indicator for depression and anxiety treatment outcomes.
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Affiliation(s)
- Jessica I L Beard
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Jaime Delgadillo
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, United Kingdom
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Bei B, Asarnow LD, Krystal A, Edinger JD, Buysse DJ, Manber R. Treating insomnia in depression: Insomnia related factors predict long-term depression trajectories. J Consult Clin Psychol 2019; 86:282-293. [PMID: 29504795 DOI: 10.1037/ccp0000282] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has been associated with poorer outcomes for both conditions. However, individual differences in depressive symptom trajectories during and after treatment are poorly understood in comorbid insomnia and depression. This study explored the heterogeneity in long-term depression change trajectories, and examined their correlates, particularly insomnia-related characteristics. METHOD Participants were 148 adults (age M ± SD = 46.6 ± 12.6, 73.0% female) with insomnia and MDD who received antidepressant pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs about sleep were also assessed. RESULTS Growth mixture modeling revealed three trajectories: (a) Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value < .001) and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom reduction during treatment (p values < .001) and low depression severity at posttreatment, but increased severity over follow-up (p value < .001). (c) Optimal-Responders (13.5%) achieved most gains during early treatment (p value < .001), continued to improve (p value < .01) and maintained minimal depression during follow-ups. The classes did not differ significantly on baseline measures or treatment received, but differed on insomnia-related measures after treatment began (p values < .05): Optimal-Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about sleep. CONCLUSIONS Three depression symptom trajectories were observed among patients with comorbid insomnia and MDD. These trajectories were associated with insomnia-related constructs after commencing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes. (PsycINFO Database Record
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Affiliation(s)
- Bei Bei
- Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University
| | - Lauren D Asarnow
- Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Andrew Krystal
- School of Medicine, University of California, San Francisco
| | | | | | - Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University
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Kaster TS, Downar J, Vila-Rodriguez F, Thorpe KE, Feffer K, Noda Y, Giacobbe P, Knyahnytska Y, Kennedy SH, Lam RW, Daskalakis ZJ, Blumberger DM. Trajectories of Response to Dorsolateral Prefrontal rTMS in Major Depression: A THREE-D Study. Am J Psychiatry 2019; 176:367-375. [PMID: 30764649 DOI: 10.1176/appi.ajp.2018.18091096] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for refractory major depressive disorder, yet no studies have characterized trajectories of rTMS response. The aim of this study was to characterize response trajectories for patients with major depression undergoing left dorsolateral prefrontal cortex rTMS and to determine associated baseline clinical characteristics. METHODS This was a secondary analysis of a randomized noninferiority trial (N=388) comparing conventional 10-Hz rTMS and intermittent theta burst stimulation (iTBS) rTMS. Participants were adult outpatients who had a primary diagnosis of major depressive disorder, had a score ≥18 on the 17-item Hamilton Depression Rating Scale (HAM-D), and did not respond to one to three adequate antidepressant trials. Treatment was either conventional 10-Hz rTMS or iTBS rTMS applied to the dorsolateral prefrontal cortex, 5 days/week over 4-6 weeks (20-30 sessions). Group-based trajectory modeling was applied to identify HAM-D response trajectories, and regression techniques were used to identify associated characteristics. RESULTS Four trajectories were identified: nonresponse (N=43, 11%); rapid response (N=73, 19%); higher baseline symptoms, linear response (N=118, 30%); and lower baseline symptoms, linear response (N=154, 40%). Significant differences in response and remission rates between trajectories were detectable by week 1. There was no association between treatment protocol and response trajectory. Higher baseline scores on the HAM-D and the Quick Inventory of Depression Symptomatology-Self-Report (QIDS-SR) were associated with the nonresponse trajectory, and older age, lower QIDS-SR score, and lack of benzodiazepine use were associated with the rapid response trajectory. CONCLUSIONS Major depression shows distinct response trajectories to rTMS, which are associated with baseline clinical characteristics but not treatment protocol. These response trajectories with differential response to rTMS raise the possibility of developing individualized treatment protocols.
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Affiliation(s)
- Tyler S Kaster
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Jonathan Downar
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Fidel Vila-Rodriguez
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Kevin E Thorpe
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Kfir Feffer
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Yoshihiro Noda
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Peter Giacobbe
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Yuliya Knyahnytska
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Sidney H Kennedy
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Raymond W Lam
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Zafiris J Daskalakis
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
| | - Daniel M Blumberger
- The Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto (Kaster, Knyahnytska, Daskalakis, Blumberger); the Department of Psychiatry (Kaster, Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), the Institute of Medical Science (Downar, Giacobbe, Kennedy, Daskalakis, Blumberger), and the Dalla Lana School of Public Health (Thorpe), University of Toronto, Toronto; the MRI-Guided rTMS Clinic, Toronto Western Hospital, Toronto (Downar); the Krembil Research Institute, University Health Network, Toronto (Downar, Kennedy); the Department of Psychiatry, University of British Columbia, Vancouver (Vila-Rodriguez, Lam); the Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver (Vila-Rodriguez); the Shalvata Mental Health Center, Hod-Hasharon, Israel, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv (Feffer); the Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo (Noda); the Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto (Giacobbe); and the Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto (Kennedy)
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9
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Lou Y, Lei Y, Mei Y, Leppänen PHT, Li H. Review of Abnormal Self-Knowledge in Major Depressive Disorder. Front Psychiatry 2019; 10:130. [PMID: 30984035 PMCID: PMC6447699 DOI: 10.3389/fpsyt.2019.00130] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 02/22/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Major depressive disorder (MDD) is an affective disorder that is harmful to both physical and mental health. Abnormal self-knowledge, which refers to abnormal judgments about oneself, is a core symptom of depression. However, little research has summarized how and why patients with MDD differ from healthy individuals in terms of self-knowledge. Objective: To gain a better understanding of MDD, we reviewed previous studies that focused on the behavioral and neurological changes of self-knowledge in this illness. Main Findings: On the behavioral level, depressed individuals exhibited negative self-knowledge in an explicit way, while more heterogeneous patterns were reported in implicit results. On the neurological level, depressed individuals, as compared with non-depressed controls, showed abnormal self-referential processing in both early perception and higher cognitive processing phases during the Self-Referential Encoding Task. Furthermore, fMRI studies have reported aberrant activity in the medial prefrontal cortex area for negative self-related items in depression. These results revealed several behavioral features and brain mechanisms underlying abnormal self-knowledge in depression. Future Studies: The neural mechanism of implicit self-knowledge in MDD remains unclear. Future research should examine the importance of others' attitudes on the self-concept of individuals with MDD, and whether abnormal self-views may be modified through cognitive or pharmacological approaches. In addition, differences in abnormal self-knowledge due to genetic variation between depressed and non-depressed populations remain unconfirmed. Importantly, it remains unknown whether abnormal self-knowledge could be used as a specific marker to distinguish healthy individuals from those with MDD. Conclusion: This review extends our understanding of the relationship between self-knowledge and depression by indicating several abnormalities among individuals with MDD and those who are at risk for this illness.
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Affiliation(s)
- Yixue Lou
- College of Psychology and Sociology, Shenzhen University, Shenzhen, China.,Faculty of Education and Psychology, University of Jyväskylä, Jyväskylä, Finland.,Center for Neurogenetics, Shenzhen Institute of Neuroscience, Shenzhen, China
| | - Yi Lei
- College of Psychology and Sociology, Shenzhen University, Shenzhen, China.,Center for Neurogenetics, Shenzhen Institute of Neuroscience, Shenzhen, China
| | - Ying Mei
- College of Psychology and Sociology, Shenzhen University, Shenzhen, China.,Center for Neurogenetics, Shenzhen Institute of Neuroscience, Shenzhen, China
| | - Paavo H T Leppänen
- Faculty of Education and Psychology, University of Jyväskylä, Jyväskylä, Finland
| | - Hong Li
- College of Psychology and Sociology, Shenzhen University, Shenzhen, China.,Center for Neurogenetics, Shenzhen Institute of Neuroscience, Shenzhen, China
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10
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Karim HT, Wang M, Andreescu C, Tudorascu D, Butters MA, Karp JF, Reynolds CF, Aizenstein HJ. Acute trajectories of neural activation predict remission to pharmacotherapy in late-life depression. NEUROIMAGE-CLINICAL 2018; 19:831-839. [PMID: 30013927 PMCID: PMC6024196 DOI: 10.1016/j.nicl.2018.06.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 12/02/2022]
Abstract
Pharmacological treatment of major depressive disorder (MDD) typically involves a lengthy trial and error process to identify an effective intervention. This lengthy period prolongs suffering and worsens all-cause mortality, including from suicide, and is typically longer in late-life depression (LLD). Our group has recently demonstrated that during an open-label venlafaxine (serotonin-norepinephrine reuptake inhibitor) trial, significant changes in functional resting state connectivity occurred following a single dose of treatment, which persisted until the end of the trial. In this work, we propose an analysis framework to translate these perturbations in functional networks into predictors of clinical remission. Participants with LLD (N = 49) completed 12-weeks of treatment with venlafaxine and underwent functional magnetic resonance imaging (fMRI) at baseline and a day following a single dose of venlafaxine. Data was collected at rest as well as during an emotion reactivity task and an emotion regulation task. Remission was defined as a Montgomery-Asberg Depression Rating Scale (MADRS) ≤10 for two weeks. We computed eigenvector centrality (whole brain connectivity) and activation during the emotion regulation and emotion reactivity tasks. We employed principal components analysis, Tikhonov-regularized logistic classification, and least angle regression feature selection to predict remission by the end of the 12-week trial. We utilized ten-fold cross-validation and Receiver Operator Curves (ROC) curve analysis. To determine task-region pairs that significantly contributed to the algorithm's ability to predict remission, we used permutation testing. Using the fMRI data at both baseline and after the first dose of treatment yielded a sensitivity of 72% and a specificity of 68% (AUC = 0.77), a 15% increase in accuracy over baseline MADRS. In general, the accuracy at baseline was further improved by using the change in activation following a single dose. Activation of the frontal cortex, hippocampus, parahippocampus, caudate, thalamus, medial temporal cortex, middle cingulate, and visual cortex predicted treatment remission. Acute, dynamic trajectories of functional imaging metrics in response to a pharmacological intervention are a valuable tool for predicting treatment response in late-life depression and elucidating the mechanism of pharmacological therapies in the context of the brain's functional architecture. Neural activation changes after a single dose of antidepressants have been observed. Patients with late-life depression were treated with an antidepressant for 12 weeks. Neuroimaging data was recorded pre-treatment and after a single dose. Pre-treatment neuroimaging predicted remission at the end of the trial. Neuroimaging after a single dose improved prediction and may guide treatment.
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Affiliation(s)
- Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Maxwell Wang
- Medical Scientist Training Program, University of Pittsburgh School of Medicine and Carnegie Mellon University, University of Pittsburgh, Pittsburgh, USA
| | - Carmen Andreescu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Dana Tudorascu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Department of Biostatistics, University of Pittsburgh, Pittsburgh, USA; Department of Internal Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Meryl A Butters
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | | | - Howard J Aizenstein
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, USA.
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Abstract
PURPOSE OF REVIEW This article aims to review select applications of Transcranial Magnetic Stimulation (TMS) that have significant relevance in geriatric psychiatry. RECENT FINDINGS Small study sizes and parameter variability limit the generalizability of many TMS studies in geriatric patients. Additionally, geriatric patients have unique characteristics that can moderate the efficacy of TMS. Nonetheless, several promising experimental applications in addition to the FDA-approved indication for major depression have emerged. Cognitive impairment, neuropathic pain, and smoking cessation are experimental applications with special significance to the elderly. Cognitive impairment has been researched the most in this population and evidence thus far suggests that TMS has potential therapeutic benefit. There is also evidence to suggest benefit from TMS for neuropathic pain and smoking cessation in working age adults. TMS is consistently reported as a safe and well-tolerated treatment modality with no adverse cognitive side effects. TMS is a safe treatment modality that can be effective for certain applications in the elderly. Additional research that specifically includes older subjects is needed to replicate findings and to optimize treatment protocols for this population.
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Affiliation(s)
- Ilva G Iriarte
- Department of Psychiatry, Medical University of South Carolina (MUSC), Charleston, SC, USA.
| | - Mark S George
- Department of Psychiatry, Medical University of South Carolina (MUSC), Charleston, SC, USA.,Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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12
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Gebara MA, Kasckow J, Smagula SF, DiNapoli EA, Karp JF, Lenze EJ, Mulsant BH, Reynolds CF. The role of late life depressive symptoms on the trajectories of insomnia symptoms during antidepressant treatment. J Psychiatr Res 2018; 96:162-166. [PMID: 29069615 PMCID: PMC5698156 DOI: 10.1016/j.jpsychires.2017.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/13/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Sleep disturbances are common in late life depression; however, changes in insomnia symptoms during antidepressant treatment need to be characterized further. The objective of this study was two-fold: 1) to describe longitudinal trajectories of insomnia symptoms in older adults receiving antidepressant treatment and 2) to examine whether baseline depressive symptoms were associated with trajectories of sleep over time. METHODS Data was obtained from 680 older adults (aged ≥ 60) with major depression who participated in one of two protocolized open-label antidepressant treatment clinical trials (Maintenance Therapies in Late Life Depression [MTLD-3]; Incomplete Response in Late Life Depression: Getting to Remission [IRL-GRey]). Depression (total score minus sleep items) and sleep (sum of sleep items) outcomes were derived from the Hamilton Depression Rating Scale in the MLTD-3 and Montgomery-Asberg Depression Rating Scale in the IRL-GRey. RESULTS Both datasets identified 5 possible trajectories of insomnia symptoms with about half of the older adults having clinically significant baseline sleep disturbances and minimal improvement following a course of antidepressant treatment (i.e., sub-optimal sleep trajectory). Furthermore, across both datasets, worse baseline depression severity was associated with sub-optimal sleep trajectories. CONCLUSION In older adults receiving antidepressant treatment, those with clinically significant baseline sleep disturbances and greater depression severity may require adjunctive sleep-focused treatment to ameliorate sleep symptoms.
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Affiliation(s)
- Marie Anne Gebara
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - John Kasckow
- Beckley Health Care System, Behavioral Health, Beckley, WV
| | - Stephen F. Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elizabeth A. DiNapoli
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA
| | - Jordan F. Karp
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO
| | | | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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13
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Li W, Wang Y, Ward BD, Antuono PG, Li SJ, Goveas JS. Intrinsic inter-network brain dysfunction correlates with symptom dimensions in late-life depression. J Psychiatr Res 2017; 87:71-80. [PMID: 28017917 PMCID: PMC5336398 DOI: 10.1016/j.jpsychires.2016.12.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/09/2016] [Indexed: 11/29/2022]
Abstract
Prior studies have demonstrated dysfunctions within the core neurocognitive networks (the executive control [ECN], default mode [DMN] and salience [SN] networks) in late-life depression (LLD). Whether inter-network dysfunctional connectivity is present in LLD, and if such disruptions are associated with core symptom dimensions is unknown. A cross-sectional resting-state functional connectivity magnetic resonance imaging investigation was conducted of LLD (n = 39) and age- and gender-equated healthy comparison (HC) (n = 29) participants. Dual regression independent component analysis approach was used to identify components that represented the ECN, DMN and SN. The intrinsic inter-network connectivity was compared between LLD and HC participants and the relationship of inter-network connectivity abnormalities with dimensional measures was examined. Relative to HC participants, LLD subjects showed decreased inter-network connectivity between the bilateral ECN and default mode subcortical (thalamus, basal ganglia and ventral striatum) networks, and the left ECN and SN insula component; and increased inter-network connections between the left ECN and posterior DMN and salience (dorsal anterior cingulate) network components. Distinct inter-network connectivity abnormalities correlated with depression and anxiety severity, and executive dysfunction in LLD participants. LLD subjects also showed pronounced intra-network connectivity differences within the ECN, whereas fewer but significant DMN and SN disruptions were also detected. Investigating the intrinsic inter-network functional connectivity could provide a mechanistic framework to better understand the neural basis that underlies core symptom dimensions in LLD. Inter-network connectivity measures have the potential to be neuroimaging biomarkers of symptom dimensions comprising LLD, and may assist in developing symptom-specific treatment algorithms.
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Affiliation(s)
- Wenjun Li
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, WI, USA; Department of Biophysics, Medical College of Wisconsin, WI, USA.
| | - Yang Wang
- Department of Radiology, Medical College of Wisconsin, WI, USA.
| | - B Douglas Ward
- Department of Biophysics, Medical College of Wisconsin, WI, USA.
| | - Piero G Antuono
- Department of Neurology, Medical College of Wisconsin, WI, USA.
| | - Shi-Jiang Li
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, WI, USA; Department of Biophysics, Medical College of Wisconsin, WI, USA.
| | - Joseph S Goveas
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, WI, USA.
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Adair CE, Streiner DL, Barnhart R, Kopp B, Veldhuizen S, Patterson M, Aubry T, Lavoie J, Sareen J, LeBlanc SR, Goering P. Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:30-39. [PMID: 27310238 PMCID: PMC5302104 DOI: 10.1177/0706743716645302] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF. METHODS Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model. RESULTS In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not. CONCLUSION While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.
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Affiliation(s)
- Carol E. Adair
- Departments of Psychiatry and Community Health Sciences, University of Calgary, Calgary, Alberta
| | - David L. Streiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Ryan Barnhart
- Centre for Addiction and Mental Health, York University, Toronto, Ontario
| | - Brianna Kopp
- Mental Health Commission of Canada, Calgary, Alberta
| | - Scott Veldhuizen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Michelle Patterson
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia
| | - Tim Aubry
- School of Psychology and Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, Ontario
| | - Jennifer Lavoie
- Department of Criminology, Wilfrid Laurier University, Brantford, Ontario
| | - Jitender Sareen
- Departments of Psychiatry, Psychology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Stefanie Renée LeBlanc
- Centre de recherche et de développement en éducation, Université de Moncton, Moncton, New Brunswick
| | - Paula Goering
- Department of Psychiatry, University of Toronto, Toronto, Ontario
- Centre for Addiction and Mental Health, York University, Toronto, Ontario
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Smagula SF, Butters MA, Anderson SJ, Lenze EJ, Dew MA, Mulsant BH, Lotrich FE, Aizenstein H, Reynolds CF. Antidepressant Response Trajectories and Associated Clinical Prognostic Factors Among Older Adults. JAMA Psychiatry 2015; 72:1021-8. [PMID: 26288246 PMCID: PMC4718144 DOI: 10.1001/jamapsychiatry.2015.1324] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE More than 50% of older adults with late-life major depressive disorder fail to respond to initial treatment with first-line pharmacological therapy. OBJECTIVES To assess typical patterns of response to an open-label trial of extended-release venlafaxine hydrochloride (venlafaxine XR) for late-life depression and to evaluate which clinical factors are associated with the identified longitudinal response patterns. DESIGN, SETTING, AND PARTICIPANTS Group-based trajectory modeling was applied to data from a 12-week open-label pharmacological trial conducted in specialty care as part of the Incomplete Response in Late Life: Getting to Remission Study. Clinical prognostic factors, including domain-specific cognitive performance and individual depression symptoms, were examined in relation to response trajectories. Participants included 453 adults aged 60 years or older with current major depressive disorder. The study was conducted between August 2009 and August 2014. INTERVENTION Open-label venlafaxine XR (titrated up to 300 mg/d) for 12 weeks. MAIN OUTCOMES AND MEASURES Subgroups exhibiting similar response patterns were derived from repeated measures of overall depression severity obtained using the Montgomery-Asberg Depression Rating Scale. RESULTS Among the 453 study participants, 3 subgroups with differing baseline depression severity clearly responded to treatment: one group with the lowest baseline severity had a rapid response (n = 69 [15.23%]), and distinct responses were also apparent among groups starting at moderate (n = 108 [23.84%]) and higher (n = 25 [5.52%]) baseline symptom levels. Three subgroups had nonresponding trajectories: 2 with high baseline symptom levels (totaling 35.98%: high, nonresponse 1, n = 110 [24.28%]; high, nonresponse 2, n = 53 [11.70%]) and 1 with moderate baseline symptom levels (n = 88 [19.43%]). Several factors were independently associated with having a nonresponsive trajectory, including greater baseline depression severity, longer episode duration, less subjective sleep loss, more guilt, and more work/activity impairment (P < .05). Higher delayed memory (list recognition) performance was independently associated with having a rapid response (adjusted odds ratio = 2.22; 95% CI, 1.18-4.20). CONCLUSIONS AND RELEVANCE Based on the observed trajectory patterns, patients who have late-life depression with high baseline depression severity are unlikely to respond after 12 weeks of treatment with venlafaxine XR. However, high baseline depression severity alone may be neither a necessary nor sufficient predictor of treatment nonresponse. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00892047.
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Affiliation(s)
- Stephen F. Smagula
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meryl A. Butters
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stewart J. Anderson
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mary Amanda Dew
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Departments of Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Francis E. Lotrich
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Howard Aizenstein
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Charles F. Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh
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Olgiati P, Serretti A. Persistent benefits of slow titration of paroxetine in a six-month follow-up. Hum Psychopharmacol 2015; 30:329-33. [PMID: 25900268 DOI: 10.1002/hup.2478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/16/2015] [Accepted: 03/03/2015] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Paroxetine titration may be difficult in older individuals as they are more sensitive to side effects. The current study extends to 6 months our previously published report in which paroxetine was started at 2.5 mg/day and slowly increased by 2.5 mg on alternate days (slow titration) or rapidly titrated to target dose from 10 mg/day (standard titration) in a naturalistic setting. METHODS Here, the follow-up period was extended to 26 weeks. We performed an intent-to-treat analysis of 47 subjects from the original sample (major depressive disorder and/or generalized anxiety disorder (GAD); >60 years of age). Missing evaluations were replaced by last observations carried forward. GAD was included as a stratification factor. RESULTS Patients in whom paroxetine was slowly up-titrated were more likely to remit (84.0% vs 54.5%; p = 0.028) and had lower core depression (p = 0.0015) and psychic anxiety levels (p = 0.006) after 26 weeks. Dropout rate was 20% in the slow titration group compared with 77.3% in the standard titration arm (p < 0.001). Patients with GAD accounted for all significant associations. No substantial differences were reported between slow and standard titration groups in the subsample without GAD. CONCLUSIONS Despite some limitations, these findings suggest that paroxetine treatment should be started at lower doses in older depressed patients and slowly up-titrated. This strategy would allow to increase antidepressant response and the likelihood of completing treatment cycle in patients with high anxiety levels and GAD comorbidity.
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Affiliation(s)
- Paolo Olgiati
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Rej S, Begley A, Gildengers A, Dew MA, Reynolds CF, Butters MA. Psychosocial Risk Factors for Cognitive Decline in Late-Life Depression: Findings from the MTLD-III Study. Can Geriatr J 2015; 18:43-50. [PMID: 26180559 PMCID: PMC4487735 DOI: 10.5770/cgj.18.134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Cognitive impairment and depression frequently co-occur in late life. There remains a need to better characterize psychosocial risk factors of cognitive decline in older adults with depression. We hypothesized that certain psychosocial factors would be associated with higher risk of cognitive decline in individuals with late-life depression. Methods 130 individuals aged ≥ 65 years who had achieved remission from a major depressive episode were randomized to donepezil or placebo and then closely followed for two years. Using Cox proportional hazard models, we examined the association between baseline median household income, education level, race, marital status, and social support and cognitive decline over the follow-up. Results Lower interpersonal support (OR = 0.86 [0.74–0.99], p = .04) and lower baseline global neuropsychological score (OR = 0.56 [0.36–0.87], p = .001) predicted shorter time to conversion to MCI or dementia in univariate models. These exposures did not remain significant in multivariate analyses. Neither socioeconomic status nor other psychosocial factors independently predicted cognitive diagnostic conversion (p > .05). Conclusions We did not find reliable associations between cognitive outcome and any of the psychosocial factors examined. Future large-scale, epidemiological studies, ideally using well-validated subjective measures, should better characterize psychosocial risk factors for cognitive decline in late-life depression.
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Affiliation(s)
- Soham Rej
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Amy Begley
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ariel Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Meryl A Butters
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Brodaty H, Low LF, Liu Z, Fletcher J, Roast J, Goodenough B, Chenoweth L. Successful ingredients in the SMILE study: resident, staff, and management factors influence the effects of humor therapy in residential aged care. Am J Geriatr Psychiatry 2014; 22:1427-37. [PMID: 24119859 DOI: 10.1016/j.jagp.2013.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 08/13/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To test the hypothesis that individual and institutional-level factors influence the effects of a humor therapy intervention on aged care residents. METHODS Data were from the humor therapy group of the Sydney Multisite Intervention of LaughterBosses and ElderClowns, or SMILE, study, a single-blind cluster randomized controlled trial of humor therapy conducted over 12 weeks; assessments were performed at baseline, week 13, and week 26. One hundred eighty-nine individuals from 17 Sydney residential aged care facilities were randomly allocated to the humor therapy intervention. Professional performers called "ElderClowns" provided 9-12 weekly humor therapy 2-hour sessions, augmented by trained staff, called "LaughterBosses." Outcome measures were as follows: Cornell Scale for Depression in Dementia, Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and proxy-rated quality of life in dementia population scale. Facility-level measures were as follows: support of the management for the intervention, commitment levels of LaughterBosses, Environmental Audit Tool scores, and facility level of care provided (high/low). Resident-level measures were engagement, functional ability, disease severity, and time-in-care. Multilevel path analyses simultaneously modeled resident engagement at the individual level (repeated measures) and the effects of management support and staff commitment to humor therapy at the cluster level. RESULTS Models indicated flow-on effects, whereby management support had positive effects on LaughterBoss commitment, and LaughterBoss commitment increased resident engagement. Higher resident engagement was associated with reduced depression, agitation, and neuropsychiatric scores. CONCLUSION Effectiveness of psychosocial programs in residential aged care can be enhanced by management support, staff commitment, and active resident engagement.
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Affiliation(s)
- Henry Brodaty
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia.
| | - Lee-Fay Low
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Zhixin Liu
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer Fletcher
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Joel Roast
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Belinda Goodenough
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Lynn Chenoweth
- Dementia Collaborative Research Centre, Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
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19
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Arean PA, Niu G. Choosing treatment for depression in older adults and evaluating response. Clin Geriatr Med 2014; 30:535-51. [PMID: 25037294 DOI: 10.1016/j.cger.2014.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An update is provided on the current information regarding late life depression with regard to assessment, clinical implications, and treatment recommendations. Several treatments are considered evidence-based, but when deployed into field trials, the efficacy of these treatments falls short. It is thought that the lower impact in community trials is due in large part to patient, clinical, environmental, socio-economic, and cognitive correlates that influence treatment response. The aim is to assist providers in making decisions about what type of treatment to recommend based on a sound assessment of these clinical correlates.
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Affiliation(s)
- Patricia A Arean
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Grace Niu
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA
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20
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Lotrich FE, Butters MA, Aizenstein H, Marron MM, Reynolds CF, Gildengers AG. The relationship between interleukin-1 receptor antagonist and cognitive function in older adults with bipolar disorder. Int J Geriatr Psychiatry 2014; 29:635-44. [PMID: 24273017 PMCID: PMC4013203 DOI: 10.1002/gps.4048] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 10/15/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Cognitive impairments are a feature of bipolar disorder (BD) and could be worsened by inflammatory cytokines. We determined whether (i) serum interleukin-1 receptor antagonist (IL-1RA) was increased in elderly BD subjects; (ii) whether IL-1RA was associated with worse neurocognitive function; and (iii) whether IL-1RA was associated with white matter integrity. METHODS Twenty-one euthymic BD patients (65 +/- 9 years) with serum available for IL-1RA measures by enzyme-linked immunoassays were compared with 26 similarly aged control participants. Four factor analysis-derived z-scores and a global z-score were obtained from a battery of 21 neurocognitive tests. Diffusion tensor images were used to obtain fractional anisotropy (FA), and an automated labeling pathway algorithm was used to obtain white matter hyperintensity burden. RESULTS Interleukin-1 receptor antagonist was elevated in BD subjects compared with controls (439+/-326 pg/mL vs. 269+/-109 pg/mL; p = 0.004). Moreover, IL-1RA was inversely correlated with three cognitive function factors and global cognition (r = -0.37; p = 0.01). IL-1RA continued to correlate with global cognitive function even when covarying for either IL-6 or brain-derived neurotrophic factor. Although FA was lower in BD subjects (0.368 +/- 0.02 vs. 0.381 +/- 0.01; p = 0.02), IL-1RA was not associated with FA or white matter hyperintensity burden. CONCLUSION Elevated serum levels of IL-1RA in BD subjects, even during euthymic states, were associated with worse cognitive function. This association was not explained by co-occurring increases in IL-6, by decreased brain-derived neurotrophic factor, nor by measures of white matter integrity. These cross-sectional findings support the possibility that the IL-1 family may contribute to cognitive impairments in BD.
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Affiliation(s)
| | - Meryl A. Butters
- 3811 O’Hara Street, Pittsburgh, PA 15213, USA. Phone 412-246-5280
| | | | - Megan M. Marron
- 3811 O’Hara Street, Pittsburgh, PA 15213, USA. Phone 412-246-6442
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21
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Aizenstein HJ, Khalef A, Walker SE, Andreescu C. Magnetic resonance imaging predictors of treatment response in late-life depression. J Geriatr Psychiatry Neurol 2014; 27:24-32. [PMID: 24381231 PMCID: PMC4103612 DOI: 10.1177/0891988713516541] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In older adults, depression not only results in more years lived with disability than any other disease but it also carries additional risks of suicide, medical comorbidities, and family caregiving burden. Because it can take many months to identify an effective treatment regimen, it is of utmost importance to shorten the window of time and identify early on what medications and dosages will work effectively for individuals having depression. Late-life depression (LLD) has been associated with greater burden of age-related changes (eg, atrophy, white matter ischemic changes, and functional connectivity). Depression in midlife has been shown to alter affective reactivity and regulation, and functional magnetic resonance imaging (fMRI) studies in LLD have replicated the same abnormalities. Effective treatment can normalize these alterations. This article provides a review of the current literature using structural and functional neuroimaging to identify MRI predictors of treatment response in LLD. The majority of the literature on structural MRI has focused on the vascular depression hypothesis, and studies support the view that loss of brain volume and white matter integrity was associated with poorer treatment outcomes. Studies using fMRI have reported that lower task-based activity in the prefrontal cortex and limbic regions was associated with poorer outcome. These imaging markers may be integrated into clinical decision making to attain better treatment outcomes in the future.
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Affiliation(s)
- Howard J. Aizenstein
- University of Pittsburgh, Department of Psychiatry.,Geriatric Psychiatry Neuroimaging Lab, University of Pittsburgh
| | | | - Sarah E. Walker
- Geriatric Psychiatry Neuroimaging Lab, University of Pittsburgh
| | - Carmen Andreescu
- University of Pittsburgh, Department of Psychiatry.,Geriatric Psychiatry Neuroimaging Lab, University of Pittsburgh
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22
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Joel I, Begley AE, Mulsant BH, Lenze EJ, Mazumdar S, Dew MA, Blumberger D, Butters M, Reynolds CF. Dynamic prediction of treatment response in late-life depression. Am J Geriatr Psychiatry 2014; 22:167-76. [PMID: 23567441 PMCID: PMC3711958 DOI: 10.1016/j.jagp.2012.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 06/25/2012] [Accepted: 07/26/2012] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To identify actionable predictors of remission to antidepressant pharmacotherapy in depressed older adults and to use signal detection theory to develop decision trees to guide clinical decision making. METHOD We treated 277 participants with current major depression using open-label venlafaxine XR (up to 300 mg/day) for 12 weeks, in an NIMH-sponsored randomized, placebo-controlled augmentation trial of adjunctive aripiprazole. Multiple logistic regression and signal detection approaches identified predictors of remission in both completer and intent-to-treat samples. RESULTS Higher baseline depressive symptom severity (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.80-0.93; p <0.001), smaller symptom improvement during the first two weeks of treatment (OR: 0.96, 95% CI: 0.94-0.97; p <0.001), male sex (OR: 0.41 95% CI: 0.18-0.93; p = 0.03), duration of current episode ≥2 years (OR: 0.26, 95% CI: 0.12-0.57; p <0.001) and adequate past depression treatment (ATHF ≥3) (OR: 0.34, 95% CI: 0.16-0.74; p = 0.006) predicted lower probability of remission in the completer sample. Subjects with Montgomery Asberg (MADRS) decreasing by greater than 27% in the first 2 weeks and with baseline MADRS scores of less than 27 (percentile rank = 51) had the best chance of remission (89%). Subjects with small symptom decrease in the first 2 weeks with adequate prior treatment and younger than 75 years old had the lowest chance of remission (16%). CONCLUSION Our results suggest the clinical utility of measuring pre-treatment illness severity and change during the first 2 weeks of treatment in predicting remission of late-life major depression.
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Affiliation(s)
- Ian Joel
- University of Pittsburgh School of Medicine, Department of Psychiatry,
Pittsburgh, PA USA
| | - Amy E. Begley
- University of Pittsburgh School of Medicine, Department of Psychiatry,
Pittsburgh, PA USA
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health and Department of Psychiatry,
University of Toronto, Ontario, Canada
| | - Eric J. Lenze
- Washington University, Department of Psychiatry, St. Louis MO USA
| | - Sati Mazumdar
- University of Pittsburgh Graduate School of Public Health, Department Biostatistics,
Pittsburgh, PA USA
| | - Mary Amanda Dew
- University of Pittsburgh School of Medicine, Department of Psychiatry,
Pittsburgh, PA USA
| | - Daniel Blumberger
- Centre for Addiction and Mental Health and Department of Psychiatry,
University of Toronto, Ontario, Canada
| | - Meryl Butters
- University of Pittsburgh School of Medicine, Department of Psychiatry,
Pittsburgh, PA USA
| | - Charles F. Reynolds
- University of Pittsburgh School of Medicine, Department of Psychiatry,
Pittsburgh, PA USA,Corresponding Author: Charles F. Reynolds III, M.D., University
of Pittsburgh, 3811 O’Hara Street BT 758, Pittsburgh, PA 15213, 412-246-6426,
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Morimoto SS, Alexopoulos GS. Cognitive deficits in geriatric depression: clinical correlates and implications for current and future treatment. Psychiatr Clin North Am 2013; 36:517-31. [PMID: 24229654 PMCID: PMC3830452 DOI: 10.1016/j.psc.2013.08.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The purpose of this article is to identify the cognitive deficits commonly associated with geriatric depression and describe their clinical significance. The complex relationship between geriatric depression and dementia is summarized and possible shared mechanisms discussed. Evidence regarding whether the cognitive deficits in depression may be mitigated with medication or with computerized cognitive remediation is presented.
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Affiliation(s)
- Sarah Shizuko Morimoto
- Department of Psychiatry, Institute of Geriatric Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA.
| | - George S. Alexopoulos
- Stephen P. Tobin and Dr. Arnold M. Cooper Professor of Psychiatry, Weill Cornell Medical College, White Plains, NY
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24
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An Evaluation of IMPACT for the Treatment of Late-Life Depression in a Public Mental Health System. J Behav Health Serv Res 2013; 42:334-45. [DOI: 10.1007/s11414-013-9373-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Decreased interhemispheric coordination in treatment-resistant depression: a resting-state fMRI study. PLoS One 2013; 8:e71368. [PMID: 23936504 PMCID: PMC3732240 DOI: 10.1371/journal.pone.0071368] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 06/29/2013] [Indexed: 11/19/2022] Open
Abstract
Background Previous studies have demonstrated that patients with treatment-resistant depression (TRD) and treatment-sensitive depression (TSD) differed at neural level. However, it remains unclear if these two subtypes of depression differ in the interhemispheric coordination. This study was undertaken for two purposes: (1) to explore the differences in interhemispheric coordination between these two subtypes by using the voxel-mirrored homotopic connectivity (VMHC) method; and (2) to determine if the difference of interhemispheric coordination can be used as a biomarker(s) to differentiate TRD from both TSD and healthy subjects (HS). Methods Twenty-three patients with TRD, 22 with TSD, and 19 HS participated in the study. Data of these participants were analyzed with the VMHC and seed-based functional connectivity (FC) approaches. Results Compared to the TSD group, the TRD group showed significantly lower VMHC values in the calcarine cortex, fusiform gyrus, hippocampus, superior temporal gyrus, middle cingulum, and precentral gyrus. Lower VMHC values were also observed in the TRD group in the calcarine cortex relative to the HS group. However, the TSD group had no significant change in VMHC value in any brain region compared to the HS group. Receiver operating characteristic curves (ROC) analysis revealed that the VMHC values in the calcarine cortex had discriminatory function distinguishing patients with TRD from patients with TSD as well as those participants in the HS group. Conclusions Lower VMHC values of patients with TRD relative to those with TSD and those in the HS group in the calcarine cortex appeared to be a unique feature for patients with TRD and it may be used as an imaging biomarker to separate patients with TRD from those with TSD or HS.
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Guo WB, Liu F, Chen JD, Xu XJ, Wu RR, Ma CQ, Gao K, Tan CL, Sun XL, Xiao CQ, Chen HF, Zhao JP. Altered white matter integrity of forebrain in treatment-resistant depression: a diffusion tensor imaging study with tract-based spatial statistics. Prog Neuropsychopharmacol Biol Psychiatry 2012; 38:201-6. [PMID: 22504778 DOI: 10.1016/j.pnpbp.2012.03.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/21/2012] [Accepted: 03/27/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND The association between alterations of the white matter (WM) integrity in brain regions and mood dysregulation has been reported in major depressive disorder (MDD). However, there has never been a neuroimaging study in patients who have treatment-resistant depression (TRD) and are in a current treatment-resistant state. In the present study, we used diffusion tensor imaging (DTI) with tract-based spatial statistics (TBSS) method to investigate the WM integrity of different brain regions in patients who had TRD and were in a current treatment-resistant state. METHODS Twenty-three patients with TRD and Hamilton Rating Scale total score of ≥18 and 19 healthy controls matched with age, gender, and education level to patients were scanned with DTI. Thirty 4 mm thick, no gap, contiguous axial slices were acquired and fractional anisotropy (FA) images were generated for each participant. An automated TBSS approach was used to analyze the data. RESULTS Voxel-wise statistics revealed that patients with TRD had lower FA values in the right anterior limb of internal capsule, the body of corpus callosum, and bilateral external capsule compared to healthy subjects. Patients with TRD did not have increased FA values in any brain regions compared to healthy subjects. There was no correlation between the FA values in any brain region and patients' demographics and the severity of illness. CONCLUSIONS Our findings suggest the abnormalities of the WM integrity of neuronal tracts connecting cortical and subcortical nuclei and two brain hemispheres may play a key role in the pathogenesis of TRD.
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Affiliation(s)
- Wen-bin Guo
- Mental Health Institute, the Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
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Weber K, Giannakopoulos P, Bacchetta JP, Quast S, Herrmann FR, Delaloye C, Ghisletta P, De Ribaupierre A, Canuto A. Personality traits are associated with acute major depression across the age spectrum. Aging Ment Health 2012; 16:472-80. [PMID: 22128822 DOI: 10.1080/13607863.2011.630375] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVES Psychological predictors, such as personality traits, have aroused growing interest as possible predictors of late-life depression outcome in old age. It remains, however, unclear whether the cross-sectional relationship between personality traits and depression occurrence reported in younger samples is also present in the elderly. METHODS Comparisons amongst 79 outpatients with DSM-IV major depression and 102 healthy controls included assessment of the five-factor model of personality (NEO PI-R), socio-demographic variables, physical health status, as well as depression features. Two sub-groups were considered, defined as young (25-50 years) and old (60-85 years) patients. RESULTS Depressed patients showed significantly higher levels of Neuroticism and lower levels of Extraversion, Openness to Experience and Conscientiousness compared to controls. Sequential logistic regression models confirmed that the combination of increased physical burden, levels of dependency, and increased Neuroticism strongly predicts the occurrence of acute depressive symptoms. In contrast, the levels of Neuroticism did not allow for differentiating late-life from young age depression. Increased physical burden and decreased depression severity were the main predictors for this distinction. CONCLUSION Our data indicate that personality factors and depression are related, independently of patients' age. Differences in this relationship are mainly due to the intensity of depressive symptoms rather than the patients' life period. They also stress the need to consider physical health, level of dependency and severity of symptoms when studying the relationship between personality traits and mood disorders.
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Affiliation(s)
- Kerstin Weber
- Division of Liaison Psychiatry and Crisis Intervention, University Hospitals of Geneva, Switzerland.
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Carter GC, Cantrell RA, Victoria Zarotsky, Haynes VS, Phillips G, Alatorre CI, Goetz I, Paczkowski R, Marangell LB. Comprehensive review of factors implicated in the heterogeneity of response in depression. Depress Anxiety 2012; 29:340-54. [PMID: 22511365 DOI: 10.1002/da.21918] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Heterogeneity in overall response and outcomes to pharmacological treatment has been reported in several depression studies but with few sources that integrate these results. The goal of this study was to review the literature and attempt to identify nongenetic factors potentially predictive of overall response to depression treatments. METHODS A comprehensive review of the literature from the last 10 years was performed using three key databases (PubMed, EMBASE, and Cochrane). All relevant studies that met the inclusion criteria were selected and scored for their levels of evidence using the NICE scoring method. A subjective assessment of the strength of evidence for each factor was performed using predefined criteria. RESULTS Our broad search yielded 76 articles relevant to treatment heterogeneity. Sociodemographic factors, disease characteristics, and comorbidities were the most heavily researched areas. Some of the factors associated with more favorable overall response include being married, other social support, and low levels of baseline depressive symptoms. Evidence relating to baseline disease severity as a factor predictive of antidepressant response was particularly convincing among the factors reviewed. The presence of comorbid anxiety and pain contributed to worse antidepressant treatment outcomes. CONCLUSIONS Several factors either predictive of or associated with overall response to antidepressant treatment have been identified. Inclusion of factors predictive of response in the design of future trials may help tailor treatments to depression patients presenting to the average clinical practice, resulting in improved outcomes.
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Affiliation(s)
- Gebra Cuyún Carter
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
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Bogner HR, Morales KH, Reynolds CF, Cary MS, Bruce ML. Prognostic factors, course, and outcome of depression among older primary care patients: the PROSPECT study. Aging Ment Health 2012; 16:452-61. [PMID: 22296508 PMCID: PMC3323766 DOI: 10.1080/13607863.2011.638904] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVES We sought to examine whether there are patterns of evolving depression symptoms among older primary care patients that are related to prognostic factors and long-term clinical outcomes. METHOD Primary care practices were randomly assigned to Usual Care or to an intervention consisting of a depression care manager offering algorithm-based depression care. In all, 599 adults 60 years and older meeting criteria for major depression or clinically significant minor depression were randomly selected. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients according to the patterns of depression symptoms across 12 months. Depression diagnosis determined after a structured interview at 24 months was the long-term clinical outcome. RESULTS Three patterns of change in depression symptoms over 12 months were identified: high persistent course (19.1% of the sample), high declining course (14.4% of the sample), and low declining course (66.5% of the sample). Being in the intervention condition was more likely to be associated with a course of high and declining depression symptoms than high and persistent depression symptoms (OR = 2.53, 95% CI [1.01, 6.37]). Patients with a course of high and persistent depression symptoms were much more likely to have a diagnosis of major depression at 24 months compared with patients with a course of low and declining depression symptoms (adjusted OR = 16.46, 95% CI [7.75, 34.95]). CONCLUSION Identification of patients at particularly high risk of persistent depression symptoms and poor long-term clinical outcomes is important for the development and delivery of interventions.
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Affiliation(s)
- Hillary R. Bogner
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, U.S.A,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - Knashawn H. Morales
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, U.S.A
| | - Mark S. Cary
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - Martha L. Bruce
- Department of Psychiatry, Weill Medical College of Cornell University, New York, NY, U.S.A
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Liang J, Xu X, Quiñones AR, Bennett JM, Ye W. Multiple trajectories of depressive symptoms in middle and late life: racial/ethnic variations. Psychol Aging 2011; 26:761-77. [PMID: 21875216 PMCID: PMC3495237 DOI: 10.1037/a0023945] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This research aims to identify distinct courses of depressive symptoms among middle-aged and older Americans and to ascertain how these courses vary by race/ethnicity. Data came from the 1995-2006 Health and Retirement Study which involved a national sample of 17,196 Americans over 50 years of age with up to six repeated observations. Depressive symptoms were measured by an abbreviated version of the Center for Epidemiologic Studies Depression scale. Semiparametric group based mixture models (Proc Traj) were used for data analysis. Six major trajectories were identified: (a) minimal depressive symptoms (15.9%), (b) low depressive symptoms (36.3%), (c) moderate and stable depressive symptoms (29.2%), (d) high but decreasing depressive symptoms (6.6%), (e) moderate but increasing depressive symptoms (8.3%), and (f) persistently high depressive symptoms (3.6%). Adjustment of time-varying covariates (e.g., income and health conditions) resulted in a similar set of distinct trajectories. Relative to White Americans, Black and Hispanic Americans were significantly more likely to be in trajectories of more elevated depressive symptoms. In addition, they were more likely to experience increasing and decreasing depressive symptoms. Racial and ethnic variations in trajectory groups were partially mediated by SES, marital status, and health conditions, particularly when both interpersonal and intrapersonal differences in these variables were taken into account.
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Affiliation(s)
- Jersey Liang
- School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA.
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Lewis KN, Heckman BD, Himawan L. Multinomial logistic regression analysis for differentiating 3 treatment outcome trajectory groups for Headache-associated Disability. Pain 2011; 152:1718-1726. [DOI: 10.1016/j.pain.2011.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 12/12/2010] [Accepted: 02/01/2011] [Indexed: 11/27/2022]
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Andreescu C, Reynolds CF. Late-life depression: evidence-based treatment and promising new directions for research and clinical practice. Psychiatr Clin North Am 2011; 34:335-55, vii-iii. [PMID: 21536162 PMCID: PMC8442985 DOI: 10.1016/j.psc.2011.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As the population ages, successive cohorts of older adults will experience depressive disorders. Late-life depression (LLD) carries additional risk for suicide, medical comorbidity, disability, and family caregiving burden. Although response and remission rates to pharmacotherapy and electroconvulsive therapy are comparable with those in midlife depression, relapse rates are higher, underscoring the challenge to achieve and maintain wellness. This article reviews the evidence base for LLD treatment options and provides an analysis of treatment options for difficult-to-treat LLD variants (eg, psychotic depression, vascular depression). Treatment algorithms are also reviewed based on predictors of response and promising novel treatment options.
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Affiliation(s)
- Carmen Andreescu
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O’Hara Street, 247 Sterling Plaza, Pittsburgh, PA 15213, USA
| | - Charles F. Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O’Hara Street, 758 Bellefield Towers, Pittsburgh, PA 15213, USA,Corresponding author.
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Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects. Psychiatr Clin North Am 2011; 34:377-401, viii. [PMID: 21536164 PMCID: PMC3099466 DOI: 10.1016/j.psc.2011.03.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This systematic review evaluates the efficacy of psychosocial interventions for the acute treatment of late-life depression and identifies predictors of treatment outcomes and moderators of treatment effects. Problem-solving therapy, cognitive behavioral therapy, and treatment initiation and participation program have supportive evidence of efficacy, pending replication. Although the data on predictors of treatment outcomes and moderators of treatment effects are preliminary, it appears that baseline anxiety and stress level, personality disorders, endogenous depression, and reduced self-rated health predict worse depression outcomes. Future research may examine the moderating effects of baseline depression severity and identify other clinical or demographic moderators.
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Chu D, Gildengers AG, Houck PR, Anderson SJ, Mulsant BH, Reynolds CF, Kupfer DJ. Does age at onset have clinical significance in older adults with bipolar disorder? Int J Geriatr Psychiatry 2010; 25:1266-71. [PMID: 20082348 PMCID: PMC3061322 DOI: 10.1002/gps.2466] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE While age at onset may be useful in explaining some of the heterogeneity of bipolar disorder (BD) in large, mixed age groups, investigations to date have found few meaningful clinical differences between early versus late age at onset in older adults with BD. METHODS Data were collected from sixty-one subjects aged 60 years and older, mean (SD) age 67.6 (7.0), with BD I (75%) and II (25%). Subjects were grouped by early (< 40 years; n = 43) versus late (≥ 40 years; n = 18) age at onset. Early versus late onset groups were compared on psychiatric comorbidity, medical burden, and percentage of days well during study participation. RESULTS Except for family history of major psychiatric illnesses, there were no differences between the groups on demographic or clinical variables. Patients with early and late onset experienced similar percentages of days well; however, those with early onset had slightly more percentage of days depressed than those with late onset (22% versus 13%) CONCLUSION Distinguishing older adults with BD by early or late age at onset has limited clinical usefulness.
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Affiliation(s)
- David Chu
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
| | - Ariel G. Gildengers
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
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Bipolar Disorder Center for Pennsylvanians, University of Pittsburgh School of Medicine, PA, USA
| | - Patricia R. Houck
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
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Bipolar Disorder Center for Pennsylvanians, University of Pittsburgh School of Medicine, PA, USA
| | - Stewart J. Anderson
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
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Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - Benoit H. Mulsant
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
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Bipolar Disorder Center for Pennsylvanians, University of Pittsburgh School of Medicine, PA, USA
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Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Canada
| | - Charles F. Reynolds
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
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Bipolar Disorder Center for Pennsylvanians, University of Pittsburgh School of Medicine, PA, USA
| | - David J. Kupfer
- Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA
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Bipolar Disorder Center for Pennsylvanians, University of Pittsburgh School of Medicine, PA, USA
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Talbot F, Harris GE, French DJ. Treatment outcome in psychiatric inpatients: the discriminative value of self-esteem. Int J Psychiatry Med 2010; 39:227-41. [PMID: 19967897 DOI: 10.2190/pm.39.3.b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
UNLABELLED Self-esteem has been identified as an important clinical variable within various psychological and psychiatric conditions. Surprisingly, its prognostic and discriminative value in predicting treatment outcome has been understudied. OBJECTIVE The current study aims to assess, in an acute psychiatric setting, the comparative role of self-esteem in predicting treatment outcome in depression, anxiety, and global symptom severity, while controlling for socio-demographic variables, pre-treatment symptom severity, and personality pathology. DESIGN Treatment outcome was assessed with pre- and post-treatment measures. METHOD A heterogeneous convenience sample of 63 psychiatric inpatients completed upon admission and discharge self-report measures of depression, anxiety, global symptom severity, and self-esteem. RESULTS A significant one-way repeated-measures multivariate analysis of variance (MANOVA) followed up by analyses of variance (ANOVAs) revealed significant reductions in depression (eta2 = .72), anxiety (eta2 = .55), and overall psychological distress (eta2 = .60). Multiple regression analyses suggested that self-esteem was a significant predictor of short-term outcome in depression but not for anxiety or overall severity of psychiatric symptoms. The regression model predicting depression outcome explained 32% of the variance with only pre-treatment self-esteem contributing significantly to the prediction. CONCLUSIONS The current study lends support to the importance of self-esteem as a pre-treatment patient variable predictive of psychiatric inpatient treatment outcome in relation with depressive symptomatology. Generalization to patient groups with specific diagnoses is limited due to the heterogeneous nature of the population sampled and the treatments provided. Implications for clinical practice and future research are discussed.
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Affiliation(s)
- France Talbot
- Ecole de Psychologie, Université de Moncton, Canada.
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Lisanby SH, Husain MM, Rosenquist PB, Maixner D, Gutierrez R, Krystal A, Gilmer W, Marangell LB, Aaronson S, Daskalakis ZJ, Canterbury R, Richelson E, Sackeim HA, George MS. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsychopharmacology 2009; 34:522-34. [PMID: 18704101 DOI: 10.1038/npp.2008.118] [Citation(s) in RCA: 221] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Randomized controlled trials support the antidepressant efficacy of transcranial magnetic stimulation (TMS); however, there is individual variability in the magnitude of response. Examination of response predictors has been hampered by methodological limitations such as small sample sizes and single-site study designs. Data from a multisite sham-controlled trial of the antidepressant efficacy of TMS provided an opportunity to examine predictors of acute outcome. An open-label extension for patients who failed to improve provided the opportunity for confirmatory analysis. Treatment was administered to the left dorsolateral prefrontal cortex at 10 pulses per second, 120% of motor threshold, for a total of 3000 pulses per day. Change on the Montgomery-Asberg Depression Rating Scale after 4 weeks was the primary efficacy outcome. A total of 301 patients with nonpsychotic unipolar major depression at 23 centers were randomized to active or sham TMS. Univariate predictor analyses showed that the degree of prior treatment resistance in the current episode was a predictor of positive treatment outcome in both the controlled study and the open-label extension trial. In the randomized trial, shorter duration of current episode was also associated with a better outcome. In the open-label extension study, absence of anxiety disorder comorbidity was associated with an improved outcome, but duration of current episode was not. The number of prior treatment failures was the strongest predictor for positive response to acute treatment with TMS. Shorter duration of current illness and lack of anxiety comorbidity may also confer an increased likelihood of good antidepressant response to TMS.
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Affiliation(s)
- Sarah H Lisanby
- Division of Brain Stimulation and Therapeutic Modulation, Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY 10032, USA.
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Rosen J, Mulsant BH, Marino P, Groening C, Young RC, Fox D. Web-based training and interrater reliability testing for scoring the Hamilton Depression Rating Scale. Psychiatry Res 2008; 161:126-30. [PMID: 18760843 PMCID: PMC2590758 DOI: 10.1016/j.psychres.2008.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 10/17/2007] [Accepted: 03/02/2008] [Indexed: 11/28/2022]
Abstract
Despite the importance of establishing shared scoring conventions and assessing interrater reliability in clinical trials in psychiatry, these elements are often overlooked. Obstacles to rater training and reliability testing include logistic difficulties in providing live training sessions, or mailing videotapes of patients to multiple sites and collecting the data for analysis. To address some of these obstacles, a web-based interactive video system was developed. It uses actors of diverse ages, gender and race to train raters how to score the Hamilton Depression Rating Scale and to assess interrater reliability. This system was tested with a group of experienced and novice raters within a single site. It was subsequently used to train raters of a federally funded multi-center clinical trial on scoring conventions and to test their interrater reliability. The advantages and limitations of using interactive video technology to improve the quality of clinical trials are discussed.
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Affiliation(s)
- Jules Rosen
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States.
| | - Benoit H. Mulsant
- Department of Psychiatry, University of Pittsburgh School of Medicine, PA,Geriatric Mental Health Program, Centre for Addiction and Mental Health, and University of Toronto
| | - Patricia Marino
- Department of Psychiatry, Weill Medical College of Cornell University
| | | | - Robert C. Young
- Department of Psychiatry, Weill Medical College of Cornell University
| | - Debra Fox
- Fox Learning Systems, Inc; Pittsburgh, PA
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Areán PA, Ayalon L, Jin C, McCulloch CE, Linkins K, Chen H, McDonnell-Herr B, Levkoff S, Estes C. Retracted: Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study. Int J Geriatr Psychiatry 2008; 23. [PMID: 18613209 DOI: 10.1002/gps.2047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Areán PA, Ayalon L, Jin C, McCulloch CE, Linkins K, Chen H, McDonnell-Herr B, Levkoff S, Estes C. Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study. Int J Geriatr Psychiatry 2008; 23:1086-92. [PMID: 18727133 DOI: 10.1002/gps.2100] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services. METHOD We identified 2,022 (48% minorities) primary care patients 65 years and older, who met study inclusion criteria and had either alcohol misuse, depression, and/or anxiety. They were randomized to receive treatment for these disorders in the primary care clinic or to a brokerage case management model that linked patients to community-based services. Service use and clinical outcomes were collected at baseline, three months and six months post randomization on all participants. RESULTS Access to and participation in mental health /substance abuse services was greater in the integrated model than in referral; there were no treatment by ethnicity effects. There were no treatment effects for any of the clinical outcomes; Whites and older minorities in both integrated and referral groups failed to show clinically significant improvement in symptoms and physical functioning at 6 months. CONCLUSIONS While providing services in primary care results in better access to and use of these services, accessing these services is not enough for assuring adequate clinical outcomes.
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Andreescu C, Mulsant BH, Houck PR, Whyte EM, Mazumdar S, Dombrovski AY, Pollock BG, Reynolds CF. Empirically derived decision trees for the treatment of late-life depression. Am J Psychiatry 2008; 165:855-62. [PMID: 18450930 PMCID: PMC2840395 DOI: 10.1176/appi.ajp.2008.07081340] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Several predictors of treatment response in late-life depression have been reported in the literature. The aim of this analysis was to develop a clinically useful algorithm that would allow clinicians to predict which patients will likely respond to treatment and thereby guide clinical decision making. METHOD A total of 461 patients with late-life depression were treated under structured conditions for up to 12 weeks and assessed weekly with the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The authors developed a hierarchy of predictors of treatment response using signal-detection theory. The authors developed two models, one minimizing false predictions of future response and one minimizing false predictions of future nonresponse, to offer clinicians two clinically useful treatment algorithms. RESULTS In the first model, early symptom improvement (defined by the relative change in HAM-D-17 total score from baseline to week 4), lower baseline anxiety, and an older age of onset predict response at 12 weeks. In the second model, early symptom improvement represents the principal guide in tailoring treatment, followed by baseline anxiety level, baseline sleep disturbance, and--for a minority of patients--the adequacy of previous antidepressant treatment. CONCLUSIONS Our two models, developed to help clinicians in different clinical circumstances, illustrate the possibility of tailoring the treatment of late-life depression based on clinical characteristics and confirm the importance of early observed changes in clinical status.
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Twelve-year depressive symptom trajectories and their predictors in a community sample of older adults. Int Psychogeriatr 2008; 20:221-36. [PMID: 18234145 PMCID: PMC2743537 DOI: 10.1017/s1041610207006667] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The aim of this study is to understand the long-term course and outcomes of depressive symptoms among older adults in the community by examining trajectories of depressive symptoms over time and identifying profiles of depressive symptoms predicting different trajectories. METHOD We measured depressive symptoms biennially for up to 12 years, using the modified Center for Epidemiological Studies-Depression (mCES-D) scale, in 1260 community-based adults aged 65+ years. We determined latent trajectories of total mCES-D scores over time. We identified symptom profiles based on subgroups of baseline depressive symptoms derived from factor analysis, and examined their associations with the different trajectories. RESULTS Six trajectories were identified. Two had one or no depressive symptoms at baseline and flat trajectories during follow-up. Two began with low baseline symptom scores and then diverged; female sex and functional disability were associated with future increases in depressive symptoms. Two trajectories began with high baseline scores but had different slopes: the higher trajectory was associated with medical burden, higher overall baseline score, and higher baseline scores on symptom profiles including low self-esteem, interpersonal difficulties, neurovegetative symptoms, and anhedonia. Mortality was higher among those in the higher trajectories. CONCLUSIONS In the community at large, those with minimal depressive symptoms are more likely to experience future increases in symptoms if they are women and have functional disability. Among those with higher current symptom levels, depression is more likely to persist over time in individuals who have greater medical burden and specific depressive symptoms.
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Johnson JG, Zhang B, Prigerson HG. Investigation of a developmental model of risk for depression and suicidality following spousal bereavement. Suicide Life Threat Behav 2008; 38:1-12. [PMID: 18355104 DOI: 10.1521/suli.2008.38.1.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Data from a community-based multi-wave investigation were used to examine a developmental model of risk for depression and suicidality following the death of a spouse. Measures of perceived parental affection and control during childhood were administered to 218 widowed adults 11 months after the death of the spouse. Self-esteem, spousal dependency, depression, and suicidality were assessed 9 months later. Dependency on the deceased spouse mediated a significant association between retrospectively reported parental control during childhood and post-loss depressive symptoms. Depressive symptoms mediated significant associations of dependency on the deceased spouse and low self-esteem with suicidal ideation and behavior.
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Affiliation(s)
- Jeffrey G Johnson
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY 10032, USA.
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Pinquart M, Duberstein PR, Lyness JM. Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: a meta-analysis. Aging Ment Health 2007; 11:645-57. [PMID: 18074252 DOI: 10.1080/13607860701529635] [Citation(s) in RCA: 193] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The goal of the present study was to assess the effects of psychotherapy and other behavioral interventions on depressive symptoms in clinically depressed older patients. METHODS We used meta-analysis to examine the effects of 57 controlled intervention studies. RESULTS On average, self-rated depression improved by d=0.84 standard deviation units and clinician-rated depression improved by d=0.93. Effect sizes were large for cognitive and behavioral therapy (CBT) and reminiscence; and medium for psychodynamic therapy, psychoeducation, physical exercise and supportive interventions. Age differences in treatment effects were not observed. Weaker effects were found in studies that used an active control group and in studies of physically ill or cognitively impaired patients. Studies of samples comprised exclusively of patients suffering from major depression (versus other mood disorders) also yielded weaker intervention effects. On average, 18.9% of participants did not complete the intervention, with higher dropout rates reported in group (versus individual) interventions and in longer interventions. CONCLUSIONS We conclude that cognitive-behavioral therapy and reminiscence are particularly well-established and acceptable forms of depression treatment. Interventions with 7-12 sessions may optimize effectiveness while minimizing dropout rates. For physically and cognitively impaired patients, modifications in treatment format and/or content might be useful, such as combining psychotherapy with social work interventions and pharmacotherapy.
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Affiliation(s)
- M Pinquart
- Department of Psychology, Philipps University Marburg, Germany.
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Saghafi R, Brown C, Butters MA, Cyranowski J, Dew MA, Frank E, Gildengers A, Karp JF, Lenze EJ, Lotrich F, Martire L, Mazumdar S, Miller MD, Mulsant BH, Weber E, Whyte E, Morse J, Stack J, Houck PR, Bensasi S, Reynolds CF. Predicting 6-week treatment response to escitalopram pharmacotherapy in late-life major depressive disorder. Int J Geriatr Psychiatry 2007; 22:1141-6. [PMID: 17486678 PMCID: PMC3579589 DOI: 10.1002/gps.1804] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Approximately half of older patients treated for major depressive disorder (MDD) do not achieve symptomatic remission and functional recovery with first-line pharmacotherapy. This study aims to characterize sociodemographic, clinical, and neuropsychologic correlates of full, partial, and non-response to escitalopram monotherapy of unipolar MDD in later life. METHODS One hundred and seventy-five patients aged 60 and older were assessed at baseline on demographic variables, depression severity, hopelessness, anxiety, cognitive functioning, co-existing medical illness burden, social support, and quality of life (disability). Subjects received 10 mg/d of open-label escitalopram and were divided into full (n = 55; 31%), partial (n = 75; 42.9%), and non-responder (n = 45; 25.7%) groups based on Hamilton depression scores at week 6. Univariate followed by multivariate analyses tested for differences between the three groups. RESULTS Non-responders to treatment were found to be more severely depressed and anxious at baseline than both full and partial responders, more disabled, and with lower self-esteem than full responders. In general partial responders resembled full responders more than they resembled non-responders. In multivariate models, more severe anxiety symptoms (both psychological and somatic) and lower self-esteem predicted worse response status at 6 weeks. CONCLUSION Among treatment-seeking elderly persons with MDD, higher anxiety symptoms and lower self-esteem predict poorer response after six weeks of escitalopram treatment.
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Affiliation(s)
- Ramin Saghafi
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Charlotte Brown
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Meryl A. Butters
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Jill Cyranowski
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Mary Amanda Dew
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Ellen Frank
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Ariel Gildengers
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Jordan F. Karp
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Eric J. Lenze
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Francis Lotrich
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Lynn Martire
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Sati Mazumdar
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Mark D. Miller
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Benoit H. Mulsant
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
- Centre for Addiction and Mental Health, University of Toronto, Canada
| | - Elizabeth Weber
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Ellen Whyte
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Jennifer Morse
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Jacqueline Stack
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Patricia R. Houck
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Salem Bensasi
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Charles F. Reynolds
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, the Advanced Center for Interventions and Services Research in Late-Life Mood Disorders; the John A. Hartford Center of Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine; Project EXPORT at the Center for Minority Health, NIH/NCMHD P60 MD-000-207, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
- Correspondence to: Dr C. F. Reynolds, III, 3811 O’Hara Street, Pittsburgh, PA 15213, USA.
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Nelson JC, Holden K, Roose S, Salzman C, Hollander SB, Betzel JV. Are there predictors of outcome in depressed elderly nursing home residents during treatment with mirtazapine orally disintegrating tablets? Int J Geriatr Psychiatry 2007; 22:999-1003. [PMID: 17447229 DOI: 10.1002/gps.1779] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Treatment studies of depression in residential care are limited. Reports of predictors of response are rare. In the largest nursing home prospective antidepressant trial reported, we examined predictors of response. METHODS This was a 12-week open-label study of mirtazapine orally disintegrating tablets performed in 30 US nursing homes. Subjects were men and women aged >or=70, with a Mini Mental State Exam (MMSE) score >or=10, who had a depressive disorder that required antidepressant treatment. Mirtazapine was started at 15 mg at bedtime, and adjusted to 15-45 mg/day. A 16-item Hamilton Depression Rating Scale was used to assess depression at baseline, weeks 2, 4, 8, and 12 or early termination. RESULTS One hundred and twenty-four patients received at least one dose of study drug and of these, 119 had at least one post-drug assessment. Mean age was 82.9 years and 72% were female. Response rates at 12 weeks were 47% on the HAMD and 54% on the CGI. Age, sex, MMSE score, medical burden, history of prior depression, and baseline HAMD severity were not significantly associated with HAMD response (>or=50% improvement) and in most cases correlations were trivial, <0.1. Advanced age, medical burden, and cognitive impairment did not predict adverse events. CONCLUSIONS In this sample of depressed nursing home residents treated with mirtazapine orally disintegrating tablets, advanced age, medical illness, and cognitive impairment did not predict response. The findings suggest that these variables need not be viewed as obstacles to treatment.
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Affiliation(s)
- J Craig Nelson
- University California San Francisco, San Francisco, CA, USA.
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Gex-Fabry M, Gervasoni N, Eap CB, Aubry JM, Bondolfi G, Bertschy G. Time course of response to paroxetine: influence of plasma level. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31:892-900. [PMID: 17395353 DOI: 10.1016/j.pnpbp.2007.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 02/03/2007] [Accepted: 02/06/2007] [Indexed: 11/22/2022]
Abstract
Early improvement of depression severity is considered an important therapeutic goal, predictive of later remission. The present study aimed at testing the hypothesis that plasma concentration might influence the time course of response to paroxetine. Eighty-four patients with a severe depressive episode started paroxetine 20 mg/day, with a possible dose adjustment to 30 mg/day after 2 weeks. Severity of depression (Montgomery-Asberg Depression Rating Scale) was assessed at weeks 0, 2 and 4 for all patients, and every 2 weeks thereafter until discontinuation. Median duration on paroxetine was 6 weeks (range 4-18 weeks). Plasma concentration was measured at steady-state after 2 weeks at 20 mg/day. In a first stage, pattern analysis led to distinguish patients with non-response, non-persistent response, early persistent response (obtained at week 2) and delayed persistent response (week 4 or later). Comparison of patients with (n=29, 34.5%) and without persistent response (n=55, 65.5%) did not reveal any significant difference, whereas focus on patients with persistent response indicated that shorter time to response was significantly associated with shorter duration of current episode (r(S)=0.54, p=0.003) and higher plasma level (r(S)=-0.47, p=0.011). In a second stage, a sigmoid mixed effects model was developed that adequately fitted depression severity versus time profiles among patients with persistent response (n=157 data for 29 patients). Estimated median time to response was 3.2 weeks (range 0.9-6.6). Higher paroxetine concentration, younger age and shorter episode duration were confirmed as significant determinants of a shorter time to response (likelihood ratio tests, p<0.005). The present study supports the hypothesis that higher paroxetine concentration might contribute to hasten relief of depressive symptoms in severely depressed patients.
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Affiliation(s)
- Marianne Gex-Fabry
- Service of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, 2 chemin du Petit-Bel-Air, CH-1225 Chêne-Bourg, Switzerland.
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Andreescu C, Lenze EJ, Dew MA, Begley AE, Mulsant BH, Dombrovski AY, Pollock BG, Stack J, Miller MD, Reynolds CF. Effect of comorbid anxiety on treatment response and relapse risk in late-life depression: controlled study. Br J Psychiatry 2007; 190:344-9. [PMID: 17401042 DOI: 10.1192/bjp.bp.106.027169] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Comorbid anxiety is common in depressive disorders in both middle and late life, and it affects response to antidepressant treatment. AIMS To examine whether anxiety symptoms predict acute and maintenance (2 years) treatment response in late-life depression. METHOD Data were drawn from a randomised double-blind study of pharmacotherapy and interpersonal psychotherapy for patients age 70 years and over with major depression. Anxiety symptoms were measured using the Brief Symptom Inventory. Survival analysis tested the effect of pre-treatment anxiety on response and recurrence. RESULTS Patients with greater pretreatment anxiety took longer to respond to treatment and had higher rates of recurrence. Actuarial recurrence rates were 29% (pharmacotherapy, lower anxiety), 58% (pharmacotherapy, higher anxiety), 54% (placebo, lower anxiety) and 81% (placebo, higher anxiety). CONCLUSIONS Improved identification and management of anxiety in late-life depression are needed to achieve response and stabilise recovery.
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Affiliation(s)
- Carmen Andreescu
- Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Room E 823, Pittsburgh, PA15213, USA.
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