Effects of Patient Preferences on Outcomes in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) Study

Predicting optimal treatment allocation for cognitive analytic-guided self-help versus cognitive behavioural-guided self-help

OBJECTIVES

Given the ubiquity in routine services of low-intensity guided self-help (GSH) psychological interventions, better patient selection for these brief interventions would be organizationally efficient. This study therefore sought to define who would respond best to two different types of GSH for anxiety to enable better future treatment matching.

METHODS

The study used outcome data from a patient preference trial (N = 209) comparing cognitive analytic therapy-guided self-help (CAT-GSH) with cognitive behavioural therapy-guided self-help (CBT-GSH). Elastic Net regularization and Boruta random forest variable selection methods were applied. Regression models calculated the patient advantage index (PAI) to designate which GSH was likely the most effective for each patient. Outcomes were compared for those receiving their PAI-indicated optimal and non-optimal GSH.

RESULTS

Lower baseline depression and anxiety severity predicted better outcomes for both types of GSH. Patient preference status was not associated with outcome during either GSH. Sixty-three % received their model indicating optimal GSH and these had significantly higher rates of reliable and clinically significant reductions in anxiety at both post-treatment (35.9% vs. 16.6%) and follow-up (36.6% vs. 19.2%). No single patient with a large PAI had a reliable and clinically significant reduction in anxiety at post-treatment or follow-up when they did not receive their optimal GSH.

CONCLUSIONS

Treatment matching algorithms have the potential to support evidenced-based treatment selection for GSH. Treatment selection and supporting patient choice needs to be integrated. Future research needs to investigate the use of the PAI for GSH treatment matching, but with larger and more balanced samples.

Patient preference effects in a randomized comparative effectiveness study of electroconvulsive therapy and ketamine for treatment resistant depression: An ELEKT-D trial secondary analysis

INTRODUCTION

Previous studies have shown patient preference can have large effects on treatment adherence and patient satisfaction. However, the direct effects of matching treatment with patient preference on efficacy and safety outcomes remain unclear. We aimed to evaluate the effects of patient preference and preference-matching on efficacy, adverse events, and adherence to electroconvulsive therapy (ECT) and intravenous (IV) ketamine treatments in a randomized clinical trial.

METHODS

Data were collected during the Patient-Centered Outcomes Research Institute (PCORI) funded ECT vs. Ketamine in Patients with Treatment Resistant Depression (ELEKT-D) study, which randomized patients to treatment with either ECT or IV ketamine across five U.S. sites. We performed post hoc-analyses on 255 patients who provided responses to a patient preference survey following treatment phase completion, which allowed us to explore the relationships between treatment preference and several treatment outcome measures.

RESULTS

Our analysis showed that (1) Ketamine was preferred by more trial participants than ECT; (2) Preference for ketamine was associated with higher likelihood of treatment response for all patients regardless of treatment assignment; (3) Preference-matching (patients receiving the treatment they indicated a moderate or strong preference for on the survey) was associated with greater likelihood of treatment response to ketamine but not ECT; (4) Preference-matching was associated with reduced rates of adverse events in ECT-treated patients. There was a trend for preference-matching potentially influencing treatment adherence.

CONCLUSIONS

Our findings suggest treatment preference-matching affects treatment effectiveness, adverse event reporting and possibly adherence. However, these associations may be contextual, modality dependent, and complex.

Metabolomics signatures of serotonin reuptake inhibitor (escitalopram), serotonin norepinephrine reuptake inhibitor (duloxetine) and cognitive-behavioral therapy on key neurotransmitter pathways in major depressive disorder

Metabolomics provides powerful tools that can inform about heterogeneity in disease and response to treatments. In this exploratory study, we employed an electrochemistry-based targeted metabolomics platform to assess the metabolic effects of three randomly-assigned treatments: escitalopram, duloxetine, and Cognitive-Behavioral Therapy (CBT) in 163 treatment-naïve outpatients with major depressive disorder. Serum samples from baseline and 12 weeks post-treatment were analyzed using targeted liquid chromatography-electrochemistry for metabolites related to tryptophan, tyrosine metabolism and related pathways. Changes in metabolite concentrations related to each treatment arm were identified and compared to define metabolic signatures of exposure. In addition, association between metabolites and depressive symptom severity (assessed with the 17-item Hamilton Rating Scale for Depression [HRSD17]) and anxiety symptom severity (assessed with the 14-item Hamilton Rating Scale for Anxiety [HRSA14]) were evaluated, both at baseline and after 12 weeks of treatment. Significant reductions in serum serotonin level and increases in tryptophan-derived indoles that are gut bacterially derived were observed with escitalopram and duloxetine arms but not in CBT arm. These include indole-3-propionic acid (I3PA), indole-3-lactic acid (I3LA) and Indoxyl sulfate (IS), a uremic toxin. Purine-related metabolites were decreased across all arms. Different metabolites correlated with improved symptoms in the different treatment arms revealing potentially different mechanisms between response to antidepressant medications and to CBT.

The impact of patient choice on uptake, adherence, and outcomes across depression, anxiety, and eating disorders: a systematic review and meta-analysis

Growing evidence highlights the critical role of patient choice of treatment, with significant benefits for outcomes found in some studies. While four meta-analyses have previously examined the association between treatment choice and outcomes in mental health, robust conclusions have been limited by the inclusion of studies with biased preference trial designs. The current systematic review included 30 studies across three common and frequently comorbid mental health disorders (depression N = 23; anxiety, N = 5; eating disorders, N = 2) including 7055 participants (Mage 42.5 years, SD 11.7; 69.5% female). Treatment choice most often occurred between psychotherapy and antidepressant medication (43.3%), followed by choice between two different forms of psychotherapy, or elements within psychotherapy (36.7%). There were insufficient studies with stringent designs to conduct meta-analyses for anxiety or eating disorders as outcomes, or for treatment uptake. Treatment choice significantly improved outcomes for depression (d = 0.17, n = 18) and decreased therapy dropout, both in a combined sample targeting depression (n = 12), anxiety (n = 4) and eating disorders (n = 1; OR = 1.46, 95% CI: 1.17, 1.83), and in a smaller sample of the depression studies alone (OR = 1.65, 95% CI: 1.05, 2.59). All studies evaluated the impact of adults making treatment choices with none examining the effect of choice in adolescents. Clear directions in future research are indicated, in terms of designing studies that can adequately test the treatment choice and outcome association in anxiety and eating disorder treatment, and in youth.

Prediction of individual patient outcomes to psychotherapy vs medication for major depression

Treatments for major depressive disorder (MDD) include antidepressant medications and evidence-based psychotherapies, which are approximately equally efficacious. Individual response to treatment, however, is variable, implying individual differences that could allow for prospective differential prediction of treatment response and personalized treatment recommendation. We used machine learning to develop predictor variables that combined demographic and clinical items from a randomized clinical trial. The variables predicted a meaningful proportion of variance in end-of-treatment depression severity for cognitive behavioral therapy (39.7%), escitalopram (32.1%), and duloxetine (67.7%), leading to a high accuracy in predicting remission (71%). Further, we used these variables to simulate treatment recommendation and found that patients who received their recommended treatment had significantly improved depression severity and remission likelihood. Finally, the prediction algorithms and treatment recommendation tool were externally validated in an independent sample. These results represent a highly promising, easily implemented, potential advance for personalized medicine in MDD treatment.

Vagus nerve stimulation in treatment-resistant depression: A one-year, randomized, sham-controlled trial

BACKGROUND

Few treatments are available for individuals with marked treatment-resistant depression (TRD).

OBJECTIVE

Evaluate the safety and effectiveness of FDA-approved adjunctive vagus nerve stimulation (VNS) in patients with marked TRD.

METHODS

This 12-month, multicenter, double-blind, sham-controlled trial included 493 adults with marked treatment-resistant major depression who were randomized to active or no-stimulation sham VNS for 12 months. The primary outcome was percent time in response across months 3-12, with response defined as a ≥50 % change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Several secondary endpoints were evaluated.

RESULTS

Overall, 88.4 % of participants completed the trial. Percent time in MADRS response did not distinguish active from sham VNS. However, ratings from on-site clinicians (Clinical Global Inventory-Impression [CGI-I]), patients (Quick Inventory of Depressive Symptomology-Self Report [QIDS-SR]), and offsite masked raters (Quick Inventory of Depressive Symptomology-Clinician [QIDS-C]) revealed antidepressant benefits significantly favoring active VNS. Active VNS demonstrated significantly more percent time in response on the CGI-I (P = 0.004) and QIDS-SR (P = 0.049), and significantly more percent time in partial response (PR; symptom improvement ≥30 %) on the CGI-I (P < 0.001) and QIDS-C (P = 0.006) versus sham VNS. Active VNS exceeded sham VNS in rate of dyspnea (P = 0.035), a known side effect of VNS. No new adverse events were identified.

CONCLUSIONS

Percent time in MADRS response did not distinguish the treatment groups, but on multiple instruments time in response and PR showed a positive treatment effect. VNS was found safe and effective in participants with marked TRD.

The hypothalamic-pituitary-thyroid axis, depression and risk of suicide: commentary, Luo et al

There is a considerable literature on the relationship of thyroid function with risk of depression and responsiveness to depression treatment. This literature is briefly reviewed here, followed by a focus on the incremental advance provided by the findings of Luo et al on autoimmune thyroiditis and suicide attempts.

Breakthroughs and challenges for generating brain network-based biomarkers of treatment response in depression

Treatment outcomes widely vary for individuals diagnosed with major depressive disorder, implicating a need for deeper understanding of the biological mechanisms conferring a greater likelihood of response to a particular treatment. Our improved understanding of intrinsic brain networks underlying depression psychopathology via magnetic resonance imaging and other neuroimaging modalities has helped reveal novel and potentially clinically meaningful biological markers of response. And while we have made considerable progress in identifying such biomarkers over the last decade, particularly with larger, multisite trials, there are significant methodological and practical obstacles that need to be overcome to translate these markers into the clinic. The aim of this review is to review current literature on brain network structural and functional biomarkers of treatment response or selection in depression, with a specific focus on recent large, multisite trials reporting predictive accuracy of candidate biomarkers. Regarding pharmaco- and psychotherapy, we discuss candidate biomarkers, reporting that while we have identified candidate biomarkers of response to a single intervention, we need more trials that distinguish biomarkers between first-line treatments. Further, we discuss the ways prognostic neuroimaging may help to improve treatment outcomes to neuromodulation-based therapies, such as transcranial magnetic stimulation and deep brain stimulation. Lastly, we highlight obstacles and technical developments that may help to address the knowledge gaps in this area of research. Ultimately, integrating neuroimaging-derived biomarkers into clinical practice holds promise for enhancing treatment outcomes and advancing precision psychiatry strategies for depression management. By elucidating the neural predictors of treatment response and selection, we can move towards more individualized and effective depression interventions, ultimately improving patient outcomes and quality of life.

Initial treatment choices for long-term remission of chronic insomnia disorder in adults: a systematic review and network meta-analysis

BACKGROUND

We aimed to evaluate the comparative efficacy and acceptability of cognitive behavioral therapy for insomnia (CBT-I), pharmacotherapy, and their combination in the long and short terms among adults with chronic insomnia disorder.

METHODS

We searched multiple databases to December 27, 2023. We included trials in hypnotic-free adults with chronic insomnia comparing at least two of CBT-I, pharmacotherapy, or their combination. We assessed the confidence in evidence using CINeMA. The primary outcome was long-term remission. Secondary outcomes included all-cause dropout and self-reported sleep continuity measures in the long term, and the same outcomes in the short term. We performed frequentist random-effects network meta-analyses (CRD42024505519).

FINDINGS

We identified 13 trials including 823 randomized participants (mean age, 47.8 years; 60% women). CBT-I was more beneficial than pharmacotherapy in the long term (median duration, 24 weeks [range, 12 to 48 weeks]; remission odds ratio, 1.82 [95% confidence interval (CI), 1.15-2.87]; [certainty of evidence: high]), while there was weaker evidence of benefit of combination against pharmacotherapy (1.71 [95% CI, 0.88-3.30: moderate]) and no clear difference of CBT-I against combination (1.07 [95% CI, 0.63-1.80: moderate]). CBT-I was associated with fewer dropouts than pharmacotherapy. Short-term outcomes favored CBT-I over pharmacotherapy except total sleep time. Given the average long-term remission rate in the pharmacotherapy-initiating arms of 28%, CBT-I resulted in a long-term remission rate of 41% (95% CI, 31%-53%) and combination 40% (95% CI, 25%-56%).

INTERPRETATION

The current study found that starting with CBT-I for chronic insomnia leads to better outcomes than pharmacotherapy. Combination may be better than pharmacotherapy alone, but unlikely to be worth the additional burden over CBT-I alone.

Assessing in-session rumination during CBT for depression: Replication and further evaluation of an observational measure

This study sought to further evaluate an observational measure of rumination that occurs during psychotherapy (i.e., in-session rumination). Specifically, the study aimed to replicate the reliability of an observational rating procedure in new therapy sessions and a new sample, clarify the relationship between in-session rumination and depressive symptoms, and evaluate for the first time the relationship between in-session rumination and self-reported rumination. A team of trained research assistants produced observational ratings of in-session rumination occurring during video-taped sessions of CBT from two separate treatment studies. Thirty-five patients with major depressive disorder (MDD) from one study had their final session rated, and 17 patients with MDD from another study had their first session rated. Results showed that the observational ratings were reliable, and that in-session rumination generally correlated with depressive symptom severity as expected, with higher in-session rumination predicting higher depressive symptom levels both cross-sectionally and longitudinally. Preliminary evidence also found that in-session rumination correlated with self-reported rumination, and exploratory analyses provided preliminary evidence supporting the incremental validity of in-session rumination for predicting depression severity after treatment. The results indicate that in-session rumination can be reliably identified during CBT sessions and consistently predicts higher depressive severity, both of which support efforts to develop treatments that specifically target rumination.

Psychosocial factors associated with treatment preference in mental health

BACKGROUND

Studies examining the effects of incorporating patients' preferences into treatment outcomes highlight their impact on crucial aspects such as reduced dropout rates and enhanced effectiveness. Recognizing individuals' rights to participate in decisions about their treatments underscores the importance of studying treatment preferences and the factors influencing these choices.

AIM

This study aims to identify treatment preferences (psychological, pharmacological, or combined) among a sample of patients and to discern the psychosocial and clinical factors influencing these preferences.

METHODS

A total of 2,133 individuals receiving care at a community mental health unit completed assessments on anxious-depressive symptoms, social and occupational adjustment, and their treatment preference. Data analysis was conducted using SPSS, with descriptive statistics, Chi-square tests, and one-way ANOVA applied.

RESULTS

Preferences for treatments were distributed as follows: Combined (49.8%), psychological (33%), and pharmacological (10.6%). Factors such as diagnosis, severity of depressive and anxious symptoms, and functional impact were related to treatment preference with a moderate effect size. Meanwhile, various sociodemographic factors correlated with the selected treatment, though with a weak effect size.

CONCLUSIONS

There is a pronounced preference for combined treatments. The significance of psychological treatments is evident, as four out of five participants favored them in their choices. Addressing these preferences calls for an exploration within the broader context of prescription freedom in mental health.

The utility of measuring daily hassles and uplifts in understanding outcomes to treatments for major depressive disorder

Little is known about the effects of common daily experiences in patients with major depressive disorder (MDD). The Daily Hassles and Uplifts Scale (HUPS) was assessed in 142 treatment-naïve adult MDD outpatients randomized to 12 weeks of treatment with either antidepressant medication (ADM) or Cognitive Behavior Therapy (CBT). Three HUPS measures were analyzed: hassle frequency (HF), uplift frequency (UF), and the mean hassle intensity to mean uplift intensity ratio (MHI:MUI). Remission after treatment was not predicted by these baseline HUPS measures and did not moderate outcomes by treatment type. In contrast, HUPS measures significantly changed with treatment and were impacted by remission status. Specifically, HF and MHI:MUI decreased and UF increased from baseline to week 12, with remission leading to significantly greater decreases in HF and MHI:MUI compared to non-remission. ADM-treated patients demonstrated significant improvements on all three HUPS measures regardless of remission status. In contrast, remitters to CBT demonstrated significant improvements in HF and MHI:MUI but not UF; among CBT non-remitters the only significant change was a reduction in HF. The changes in HUPS measures are consistent with how affective biases are impacted by treatments and support the potential value of increasing attention to positive events in CBT.

The Effects of Patient Preference on Clinical Outcome, Satisfaction and Adherence Within the Treatment of Anxiety and Depression: A Meta-Analysis

BACKGROUND

Taking patient preference into consideration has received increased attention in the last decades. We conducted a meta-analysis to estimate the effects of patient preference on clinical outcome, satisfaction and adherence regarding treatment of depression and anxiety.

METHODS

Pubmed, Embase, PsycINFO and Scopus were searched for (cluster) randomized controlled trials. Twenty-six randomized controlled clinical trials were included, comprising 3670 participants, examining the effect of patient preference regarding treatment of anxiety and depression on clinical outcome, satisfaction and/or adherence.

RESULTS

No effect of patient preference was found on clinical outcome [d = 0.06, 95% CI = (-0.03, 0.15), p = 0.16, n = 23 studies]. A small effect of patient preference was found on treatment satisfaction [d = 0.33, 95% CI = (0.08, 0.59), p = 0.01, n = 6 studies] and on treatment adherence [OR = 1.55, 95% CI = (1.28, 1.87), p < 0.001, n = 22 studies].

LIMITATIONS

Patient preference is a heterogeneous concept, future studies should strive to equalize operationalization of preference. Subgroup analyses within this study should be interpreted with caution because the amount of studies per analysed subgroup was generally low. Most studies included in this meta-analysis focused on patients with depression. The small number of studies (n = 6) on satisfaction, prevents us from drawing firm conclusions.

CONCLUSIONS

While this meta-analysis did not find a positive effect of considering patient preference on clinical outcome, it was associated with slightly better treatment satisfaction and adherence. Accommodating preference of patients with anxiety and depression can improve treatment.

TRIAL REGISTRATION

PROSPERO: CRD42020172556.

Metabolomics Signatures of serotonin reuptake inhibitor (Escitalopram), serotonin norepinephrine reuptake inhibitor (Duloxetine) and Cognitive Behavior Therapy on Key Neurotransmitter Pathways in Major Depressive Disorder

Metabolomics provides powerful tools that can inform about heterogeneity in disease and response to treatments. In this study, we employed an electrochemistry-based targeted metabolomics platform to assess the metabolic effects of three randomly-assigned treatments: escitalopram, duloxetine, and Cognitive Behavior Therapy (CBT) in 163 treatment-naïve outpatients with major depressive disorder. Serum samples from baseline and 12 weeks post-treatment were analyzed using targeted liquid chromatography-electrochemistry for metabolites related to tryptophan, tyrosine metabolism and related pathways. Changes in metabolite concentrations related to each treatment arm were identified and compared to define metabolic signatures of exposure. In addition, association between metabolites and depressive symptom severity (assessed with the 17-item Hamilton Rating Scale for Depression [HRSD17]) and anxiety symptom severity (assessed with the 14-item Hamilton Rating Scale for Anxiety [HRSA14]) were evaluated, both at baseline and after 12 weeks of treatment. Significant reductions in serum serotonin level and increases in tryptophan-derived indoles that are gut bacterially derived were observed with escitalopram and duloxetine arms but not in CBT arm. These include indole-3-propionic acid (I3PA), indole-3-lactic acid (I3LA) and Indoxyl sulfate (IS), a uremic toxin. Purine-related metabolites were decreased across all arms. Different metabolites correlated with improved symptoms in the different treatment arms revealing potentially different mechanisms between response to antidepressant medications and to CBT.

The role of T-lymphocytes in central nervous system diseases

The central nervous system (CNS) has been considered an immunologically privileged site. In the past few decades, research on inflammation in CNS diseases has mostly focused on microglia, innate immune cells that respond rapidly to injury and infection to maintain CNS homeostasis. Discoveries of lymphatic vessels within the dura mater and peripheral immune cells in the meningeal layer indicate that the peripheral immune system can monitor and intervene in the CNS. This review summarizes recent advances in the involvement of T lymphocytes in multiple CNS diseases, including brain injury, neurodegenerative diseases, and psychiatric disorders. It emphasizes that a deep understanding of the pathogenesis of CNS diseases requires intimate knowledge of T lymphocytes. Aiming to promote a better understanding of the relationship between the immune system and CNS and facilitate the development of therapeutic strategies targeting T lymphocytes in neurological diseases.

Delivery of bright light therapy within the Veterans Health Administration

BACKGROUND

Bright light therapy (BLT) is efficacious for seasonal and non-seasonal depression. However, the current state of BLT use in practice is unknown, impeding efforts to identify and address utilization gaps. This study's objective was to investigate BLT delivery in a nationwide U.S. healthcare system.

METHODS

This was a retrospective observational study of electronic medical records from all veterans who received outpatient mood disorder-related care in the Veterans Health Administration (VHA) from October 2008 through September 2020. BLT delivery was measured through the placement of light box consults.

RESULTS

Of the 3,442,826 veterans who received outpatient mood disorder care, only 57,908 (1.68 %) received a light box consult. Consults increased by 548.44 % (99.9 % credible interval: 467.36 %, 638.74 %) over the timeframe and displayed a robust yearly cycle that peaked on either December 21st or December 22nd. Past mental health treatment for a mood disorder was associated with a higher probability of a consult (relative risk = 4.79, 99.9 % CI: 4.21, 5.60). There was low representation related to veteran age, gender, race, and ethnicity.

LIMITATIONS

No information on patients who declined light boxes or actual light box use following consult placement.

CONCLUSIONS

Outpatient BLT delivery for mood disorders in the VHA remains low, despite significant growth over the past decade. It also displays a strong seasonal rhythm that peaks on the winter solstice, suggesting a limited focus on seasonal depression and a suboptimal reactive approach to changing sunlight. Overall, there exists ample opportunity for novel implementation efforts aimed at increasing utilization of BLT.

Precision psychiatry and Research Domain Criteria: Implications for clinical trials and future practice

Psychiatric disorders are associated with significant social and economic burdens, many of which are related to issues with current diagnosis and treatments. The coronavirus (COVID-19) pandemic is estimated to have increased the prevalence and burden of major depressive and anxiety disorders, indicating an urgent need to strengthen mental health systems globally. To date, current approaches adopted in drug discovery and development for psychiatric disorders have been relatively unsuccessful. Precision psychiatry aims to tailor healthcare more closely to the needs of individual patients and, when informed by neuroscience, can offer the opportunity to improve the accuracy of disease classification, treatment decisions, and prevention efforts. In this review, we highlight the growing global interest in precision psychiatry and the potential for the National Institute of Health-devised Research Domain Criteria (RDoC) to facilitate the implementation of transdiagnostic and improved treatment approaches. The need for current psychiatric nosology to evolve with recent scientific advancements and increase awareness in emerging investigators/clinicians of the value of this approach is essential. Finally, we examine current challenges and future opportunities of adopting the RDoC-associated translational and transdiagnostic approaches in clinical studies, acknowledging that the strength of RDoC is that they form a dynamic framework of guiding principles that is intended to evolve continuously with scientific developments into the future. A collaborative approach that recruits expertise from multiple disciplines, while also considering the patient perspective, is needed to pave the way for precision psychiatry that can improve the prognosis and quality of life of psychiatric patients.

Efficacy and moderators of metacognitive training for depression in older adults (MCT-Silver): A randomized controlled trial

BACKGROUND

Up to 79 % of older adults with depression do not receive treatments commensurate with guideline recommendations. Metacognitive Training-Silver (MCT-Silver) is a low-intensity group training, which aims to reduce depressive symptoms by targeting (meta)cognitive beliefs.

METHODS

A randomized controlled trial comparing MCT-Silver (n = 41) to cognitive remediation (n = 39) was conducted with older adults with major depressive disorder and/or dysthymia. Clinician-rated depression (Hamilton Depression Rating Scale [HDRS, primary outcome]), self-reported depression (Beck Depression Inventory-II [BDI-II]), negative cognitive beliefs, positive metacognitive beliefs, rumination, health status, quality of life, and neurocognitive functioning were assessed at baseline, eight weeks (post) and three months (follow-up).

RESULTS

Both groups demonstrated moderate to large reductions in depression. No superior effects of MCT-Silver on clinician-rated depression (HDRS) were detected. MCT-Silver led to greater reductions in self-reported depression and rumination at post- and follow-up. Despite this, scores at post- and follow-up assessments were similar for both groups. MCT-Silver's effect on depressive symptoms was moderated by baseline rumination, positive metacognitive beliefs and previous treatment experience. MCT-Silver was evaluated as superior according to patient appraisals.

LIMITATIONS

Conclusions are limited by divergent findings on measures of depression and that the study was conducted during the COVID-19 pandemic.

CONCLUSIONS

Whereas no superior effect of MCT-Silver was found for the primary outcome, there was a significant effect of MCT-Silver for self-reported depression and rumination. Patients endorsing rumination and positive metacognitive beliefs as well as those without previous psychological treatment may benefit more from MCT-Silver.

Suanzaoren decoction exerts its antidepressant effect via the CaMK signaling pathway

Calmodulin-dependent protein kinases (CaMKs) are widely regarded as "memory molecules" due to their role in controlling numerous neuronal functions in the brain, and the CaMK signaling pathway plays a crucial role in controlling synaptic plasticity. Suanzaoren decoction (SZRD) can improve depression-like behavior and thus has potential benefits in the clinical treatment of depression; however, its mechanism of action is not fully understood. In this study, we found that key proteins in the CaMK signaling pathway were regulated by the decoction used to treat depression. The purpose of this research was to ascertain if the SZRD's therapeutic efficacy in the treatment of depression is associated with the modulation of key proteins in the CaMK signaling pathway. A rat model of depression was created by exposing the animals to chronic, unexpected, mild stress. Model rats were given intragastric administration of SZRD or fluoxetine every morning once a day. Protein and mRNA relative expression levels of CaM, CaMK I, and CaMK IV in the hippocampus were measured by Western blot, quantitative polymerase chain reaction, and immunohistochemistry in the hippocampus. Our findings demonstrated that SZRD significantly improved the mood of depressed rats. This indicates that SZRD, by modulating the CaMK signaling system, may alleviate depressive symptoms and lessen work and life-related pressures.

Baseline depression severity as moderator on depression outcomes in psychotherapy and pharmacotherapy

BACKGROUND

Evidence-based treatments for adult depression include psychotherapy and pharmacotherapy, yet little is known about how baseline depression severity moderates treatment outcome.

OBJECTIVES

We aimed to compare the effects of psychotherapy and pharmacotherapy for adult depression and to examine the association between baseline depression severity and treatment outcome, converting multiple baseline depression measures into the scores of the Beck Depression Inventory, second edition (BDI-II).

METHODS

We conducted systematic searches in bibliographical databases up to September 2022 to identify randomized controlled trials (RCTs) in which psychotherapy was compared with pharmacotherapy in the treatment of adult depression. Various meta-regressions using the baseline depression severity as predictor of the relative effects of psychotherapy and pharmacotherapy were performed.

RESULTS

We identified 65 RCTs including 7250 participants for the meta-analyses and 56 RCTs including 5548 participants for the meta-regression. We found no significant difference between psychotherapy and pharmacotherapy (g = -0.08, 95 % CI: -0.2 to 0.04, p = 0.193) and baseline depression severity was not significantly associated with the relative effects of psychotherapy and pharmacotherapy (B = 0.0032, SE = 0.0096, p = 0.74). Results were similar in several sensitivity analyses.

LIMITATIONS

Limitations included the low quality of the included studies, and the omission of long-term effects and within-study variability.

CONCLUSIONS

We found no indication for a moderation effect of baseline depression severity on the relative effects of psychotherapy and pharmacotherapy. Thus, other factors such as availability and patients' preference must be considered when deciding for treatment options.

Navigating the Intersection of Technology and Depression Precision Medicine

This chapter primarily focuses on the progress in depression precision medicine with specific emphasis on the integrative approaches that include artificial intelligence and other data, tools, and technologies. After the description of the concept of precision medicine and a comparative introduction to depression precision medicine with cancer and epilepsy, new avenues of depression precision medicine derived from integrated artificial intelligence and other sources will be presented. Additionally, less advanced areas, such as comorbidity between depression and cancer, will be examined.

Promising new pharmacological targets for depression: The search for efficacy

Pharmacological treatment of major depressive disorder (MDD) still relies on the use of serotonergic drugs, despite their limited efficacy. A few mechanistically new drugs have been developed in recent years, but many fail in clinical trials. Several hypotheses have been proposed to explain MDD pathophysiology, indicating that physiological processes such as neuroplasticity, circadian rhythms, and metabolism are potential targets. Here, we review the current state of pharmacological treatments for MDD, as well as the preclinical and clinical evidence for an antidepressant effect of molecules that target non-serotonergic systems. We offer some insights into the challenges facing the development of new antidepressant drugs, and the prospect of finding more effectiveness for each target discussed.

Functional connectivity of salience and affective networks among remitted depressed patients predicts episode recurrence

Recurrent episodes in major depressive disorder (MDD) are common but the neuroimaging features predictive of recurrence are not established. Participants in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study who achieved remission after 12 weeks of treatment withcognitive behavior therapy, duloxetine, or escitalopram were prospectively monitored for up to 21 months for recurrence. Neuroimaging markers predictive of recurrence were identified from week 12 functional magnetic resonance imaging scans by analyzing whole-brain resting state functional connectivity (RSFC) using seeds for four brain networks that are altered in MDD. Neuroimaging correlates of established clinical predictors of recurrence, including the magnitude of depressive (Hamilton Depression Rating Scale), anxiety (Hamilton Anxiety Rating Scale) symptom severity at time of remission, and a comorbid anxiety disorder were examined for their similarity to the neuroimaging predictors of recurrence. Of the 344 patients randomized in PReDICT, 61 achieved remission and had usable scans for analysis, 9 of whom experienced recurrence during follow-up. Recurrence was predicted by: 1) increased RSFC between subcallosal cingulate cortex (SCC) and right anterior insula, 2) decreased RSFC between SCC and bilateral primary visual cortex, and 3) decreased RSFC between insula and bilateral caudate. Week 12 depression and anxiety scores were negatively correlated with RSFC strength between executive control and default mode networks, but they were not correlated with the three RSFC patterns predicting recurrence. We conclude that altered RSFC in SCC and anterior insula networks are prospective risk factors associated with MDD recurrence, reflecting additional sources of risk beyond clinical measures.

Aucubin improves chronic unpredictable mild stress-induced depressive behavior in mice via the GR/NF-κB/NLRP3 axis

Eucommia ulmoides Oliv (EUO) is a traditional therapeutic drug that tonifies the liver and kidney and may improve depression. However, the mechanism of action of the main component, aucubin (AU), is unknown. To study the therapeutic effect of AU, we constructed a chronic unpredictable mild stress (CUMS) depression model in mice. Depression-like behaviors, pathological damage, hormonal changes, inflammation, intranuclear expression of glucocorticoidreceptor (GR), and hippocampal protein expression were assessed. Immunofluorescence staining of the hippocampus showed that CUMS decreased neuronal regeneration, and axons were observed to be reduced and broken. Intracellular GR expression decreased in the hippocampus and hypothalamus, and serum levels of stress hormones increased. Furthermore, molecular changes indicative of pyroptosis were observed. AU administration reversed these changes and significantly improved the depression-like behavior induced by CUMS. Our results suggested that AU improves depression by promoting the intranuclear expression of GR and inhibiting nuclear factor-kappa B-mediated inflammatory activation-driven cell pyroptosis.

Shared and Unique Changes in Brain Connectivity Among Depressed Patients After Remission With Pharmacotherapy Versus Psychotherapy

OBJECTIVE

The authors sought to determine the shared and unique changes in brain resting-state functional connectivity (rsFC) between patients with major depressive disorder who achieved remission with cognitive-behavioral therapy (CBT) or with antidepressant medication.

METHODS

The Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) trial randomized adults with treatment-naive major depressive disorder to 12 weeks of treatment with CBT (16 1-hour sessions) or medication (duloxetine 30-60 mg/day or escitalopram 10-20 mg/day). Resting-state functional MRI scans were performed at baseline and at week 12. The primary outcome was change in the whole-brain rsFC of four seeded brain networks among participants who achieved remission.

RESULTS

Of the 131 completers with usable MRI data (74 female; mean age, 39.8 years), remission was achieved by 19 of 40 CBT-treated and 45 of 91 medication-treated patients. Three patterns of connectivity changes were observed. First, those who remitted with either treatment shared a pattern of reduction in rsFC between the subcallosal cingulate cortex and the motor cortex. Second, reciprocal rsFC changes were observed across multiple networks, primarily increases in CBT remitters and decreases in medication remitters. And third, in CBT remitters only, rsFC increased within the executive control network and between the executive control network and parietal attention regions.

CONCLUSIONS

Remission from major depression via treatment with CBT or medication is associated with changes in rsFC that are mostly specific to the treatment modality, providing biological support for the clinical practice of switching between or combining these treatment approaches. Medication is associated with broadly inhibitory effects. In CBT remitters, the increase in rsFC strength between networks involved in cognitive control and attention provides biological support for the theorized mechanism of CBT. Reducing affective network connectivity with motor systems is a shared process important for remission with both CBT and medication.

Temporal multi-step predictive modeling of remission in major depressive disorder using early stage treatment data; STAR*D based machine learning approach

BACKGROUND

Artificial intelligence is currently being used to facilitate early disease detection, better understand disease progression, optimize medication/treatment dosages, and uncover promising novel treatments and potential outcomes.

METHODS

Utilizing the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) dataset, we built a machine learning model to predict depression remission rates using same clinical data as features for each of the first three antidepressant treatment steps in STAR*D. We only used early treatment data (baseline and first follow up) in each STAR*D step to temporally analyze predictive features of remission at the end of the step.

RESULTS

Our model showed significant prediction performance across the three treatment steps, At step 1, Model accuracy was 66 %; sensitivity-65 %, specificity-67 %, positive predictive value (PPV)-65.5 %, and negative predictive value (NPV)-66.6 %. At step 2, model accuracy was 71.3 %, sensitivity-74.3 %, specificity-69 %, PPV-64.5 %, and NPV-77.9 %. At step 3, accuracy reached 84.6 %; sensitivity-69 %, specificity-88.8 %, PPV-67 %, and NPV-91.1 %. Across all three steps, the early Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) scores were key elements in predicting the final treatment outcome. The model also identified key sociodemographic factors that predicted treatment remission at different steps.

LIMITATIONS

The retrospective design, lack of replication in an independent dataset, and the use of "a complete case analysis" model in our analysis.

CONCLUSIONS

This proof-of-concept study showed that using early treatment data, multi-step temporal prediction of depressive symptom remission results in clinically useful accuracy rates. Whether these predictive models are generalizable deserves further study.

Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments : A Rapid Review

BACKGROUND

Developers of clinical practice guidelines need to take patient values and preferences into consideration when weighing benefits and harms of treatment options for depressive disorder.

PURPOSE

To assess patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder.

DATA SOURCES

MEDLINE (Ovid) and PsycINFO (EBSCO) were searched for eligible studies published from 1 January 2014 to 30 November 2022.

STUDY SELECTION

Pairs of reviewers independently screened 30% of search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts.

DATA EXTRACTION

One reviewer extracted data and assessed the certainty of evidence, and a second reviewer checked for completeness and accuracy. Two reviewers independently assessed risk of bias.

DATA SYNTHESIS

The review included 11 studies: 4 randomized controlled trials, 5 cross-sectional studies, and 2 qualitative studies. In 1 randomized controlled trial, participants reported at the start of therapy that they expected supportive-expressive psychotherapy and antidepressants to yield similar improvements. A cross-sectional study reported that non-Hispanic White participants and men generally preferred antidepressants over talk therapy, whereas Hispanic and non-Hispanic Black participants and women generally did not have a preference. Another cross-sectional study reported that the most important nonserious adverse events for patients treated with antidepressants were insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. For other comparisons and outcomes, no conclusions could be drawn because of the insufficient certainty of evidence.

LIMITATIONS

The main limitation of this review is the low or insufficient certainty of evidence for most outcomes. No evidence was available on second-step depression treatment or differences in values and preferences based on gender, race/ethnicity, age, and depression severity.

CONCLUSION

Low-certainty evidence suggests that there may be some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence is lacking or insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42020212442).

Nonpharmacologic and Pharmacologic Treatments of Adult Patients With Major Depressive Disorder: A Systematic Review and Network Meta-analysis for a Clinical Guideline by the American College of Physicians

BACKGROUND

Primary care patients and clinicians may prefer alternative options to second-generation antidepressants for major depressive disorder (MDD).

PURPOSE

To compare the benefits and harms of nonpharmacologic treatments with second-generation antidepressants as first-step interventions for acute MDD, and to compare second-step treatment strategies for patients who did not achieve remission after an initial attempt with antidepressants.

DATA SOURCES

English-language studies from several electronic databases from 1 January 1990 to 8 August 2022, trial registries, gray literature databases, and reference lists to identify unpublished research.

STUDY SELECTION

2 investigators independently selected randomized trials of at least 6 weeks' duration.

DATA EXTRACTION

Reviewers abstracted data about study design and conduct, participants, interventions, and outcomes. They dually rated the risk of bias of studies and the certainty of evidence for outcomes of interest.

DATA SYNTHESIS

65 randomized trials met the inclusion criteria; eligible data from nonrandomized studies were not found. Meta-analyses and network meta-analyses indicated similar benefits of most nonpharmacologic treatments and antidepressants as first-step treatments. Antidepressants had higher risks for discontinuation because of adverse events than most other treatments. For second-step therapies, different switching and augmentation strategies provided similar symptomatic relief. The certainty of evidence for most comparisons is low; findings should be interpreted cautiously.

LIMITATIONS

Many studies had methodological limitations or dosing inequalities; publication bias might have affected some comparisons. In some cases, conclusions could not be drawn because of insufficient evidence.

CONCLUSION

Although benefits seem to be similar among first- and second-step MDD treatments, the certainty of evidence is low for most comparisons. Clinicians and patients should focus on options with the most reliable evidence and take adverse event profiles and patient preferences into consideration.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42020204703).

How Important Is a Guide Who Has Taken Psilocybin in Psilocybin-Assisted Therapy for Depression?

Promising outcomes of Psilocybin-Assisted Therapy (PAT) for depression have generated concerted efforts to replicate, extend, and refine protocols to maximize efficacy. Psychotherapy research reveals that clients benefit most when important components of treatment align with their personal preferences. One open question related to PAT concerns the importance of the psilocybin experience of the guides (trained professionals present during acute effects). We sought to assess the importance of a guide who had used psilocybin to potential clients with depressive symptoms. Over 800 MTurk respondents with depressive symptoms rated the import of a guide who had used psilocybin relative to alternative characteristics in guides and cognitive behavioral (CBT) therapists. Importance ratings for guides who had used psilocybin significantly exceeded the "somewhat important" level (50 on a 0-100 scale), other guide-related qualities, and comparable ratings for a cognitive behavioral therapist who shared demographics, had experience with depression and received cognitive therapy personally. People of color (those who are not Caucasian) and those who had previous therapy gave significantly higher importance ratings for guides who had used psilocybin. Participants who chose to list other qualities important for guides listed very similar ones for CBT therapists, often emphasizing proper training and an empathic demeanor. Guides who have used psilocybin, who inform clients of the fact, might have advantages for facilitating PAT's antidepressant effects, as least in a subset of clients.

The ERICH3 rs11580409 polymorphism is associated with 6-month antidepressant response in depressed patients

INTRODUCTION

Major Depressive Disorder (MDD) is the current leading cause of disability worldwide. The effect of its main treatment option, antidepressant drugs (AD), is influenced by genetic and metabolic factors. The ERICH3 rs11580409(A > C) genetic polymorphism was identified as a factor influencing serotonin (5HT) levels in a pharmacometabolomics-informed genome-wide association study. It was also associated with response following AD treatment in several cohorts of depressed patients.

OBJECTIVE

Our aim was to analyze the association of the ERICH3 rs11580409(A > C) genetic polymorphism with response following AD treatment and plasma 5HT levels in METADAP, a cohort of 6-month AD-treated depressed patients.

METHODS

Clinical (n = 377) and metabolic (n = 150) data were obtained at baseline and after 3 (M3) and 6 months (M6) of treatment. Linear mixed-effects models and generalized logistic mixed-effects models were used to assess the association of the rs11580409 polymorphism with the Hamilton Depression Rating Scale (HDRS) score, response and remission rates, and plasma 5HT levels.

RESULTS

The interaction between the ERICH3 rs11580409 polymorphism and time was an overall significant factor in mixed-effects models of the HDRS score (F_3,870 = 3.35, P = 0.019). At M6, CC homozygotes had a significantly lower HDRS score compared to A allele carriers (coefficient = -3.50, 95%CI [-6.00--0.99], P = 0.019). No association between rs11580409 and 5HT levels was observed.

CONCLUSION

Our results suggest an association of rs11580409 with response following long-term AD treatment. The rs11580409 genetic polymorphism may be a useful biomarker for treatment response in major depression.

Assessing in-session rumination and its effects on CBT for depression

The study evaluated if rumination of patients during therapy (i.e., in-session rumination) relates to whether or not they do less well in CBT treatment. We developed a reliably assessed in-session rumination observational measure and evaluated its relationship to depression over the course of CBT. Rated sessions came from 63 treatment-naïve patients with major depressive disorder who participated in CBT in the PReDICT study (Dunlop et al., 2017). In-session rumination was operationalized as repetitive, negative, and passive talking about depressive topics. Trained undergraduates rated the intensity and duration of in-session rumination occurring during 57 initial therapy sessions (i.e., session one) and 45 sessions in the middle of treatment (i.e., session eight). The observational ratings were sufficiently reliable (all ICCs > 0.69). Mixed model results indicated that greater intensity of in-session rumination during the initial treatment session predicted higher levels of subsequent clinician-rated depressive symptoms (p < .023). Regression results indicated that greater intensity and duration of in-session rumination at session 8 significantly predicted higher clinician-rated symptoms at end of treatment (p's < 0.02). In-session rumination intensity and duration were not, however, related to subsequent self-reported depressive symptoms. The results support efforts to identify which patients might benefit from rumination-specific interventions.

A systematic meta-review of patient-level predictors of psychological therapy outcome in major depressive disorder

BACKGROUND

Psychological therapies are effective for treating major depressive disorder, but current clinical guidelines do not provide guidance on the personalization of treatment choice. Established predictors of psychotherapy treatment response could help inform machine learning models aimed at predicting individual patient responses to different therapy options. Here we sought to comprehensively identify known predictors.

METHODS

EMBASE, Medline, PubMed, PsycINFO were searched for systematic reviews with or without meta-analysis published until June 2020 to identify individual patient-level predictors of response to psychological treatments. 3113 abstracts were identified and 300 articles assessed. We qualitatively synthesized our findings by predictor category (sociodemographic; symptom profile; social support; personality features; affective, cognitive, and behavioural; comorbidities; neuroimaging; genetics) and treatment type. We used the AMSTAR 2 to evaluate the quality of included reviews.

RESULTS

Following screening and full-text assessment, 27 systematic reviews including 12 meta-analyses were eligible for inclusion. 74 predictors emerged for various psychological treatments, primarily cognitive behavioural therapy, interpersonal therapy, and mindfulness-based cognitive therapy.

LIMITATIONS

A paucity of studies examining predictors of psychological treatment outcome, as well as methodological heterogeneities and publication biases limit the strength of the identified predictors.

CONCLUSIONS

The synthesized predictors could be used to supplement clinical decision-making in selecting psychological therapies based on individual patient characteristics. These predictors could also be used as a priori input features for machine learning models aimed at predicting a given patient's likelihood of response to different treatment options for depression, and may contribute toward the development of patient-specific treatment recommendations in clinical guidelines.

Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis

BACKGROUND

Childhood trauma is a common and potent risk factor for developing major depressive disorder in adulthood, associated with earlier onset, more chronic or recurrent symptoms, and greater probability of having comorbidities. Some studies indicate that evidence-based pharmacotherapies and psychotherapies for adult depression might be less efficacious in patients with a history of childhood trauma than patients without childhood trauma, but findings are inconsistent. Therefore, we examined whether individuals with major depressive disorder, including chronic forms of depression, and a reported history of childhood trauma, had more severe depressive symptoms before treatment, had more unfavourable treatment outcomes following active treatments, and were less likely to benefit from active treatments relative to a control condition, compared with individuals with depression without childhood trauma.

METHODS

We did a comprehensive meta-analysis (PROSPERO CRD42020220139). Study selection combined the search of bibliographical databases (PubMed, PsycINFO, and Embase) from Nov 21, 2013, to March 16, 2020, and full-text randomised clinical trials (RCTs) identified from several sources (1966 up to 2016-19) to identify articles in English. RCTs and open trials comparing the efficacy or effectiveness of evidence-based pharmacotherapy, psychotherapy, or combination intervention for adult patients with depressive disorders and the presence or absence of childhood trauma were included. Two independent researchers extracted study characteristics. Group data for effect-size calculations were requested from study authors. The primary outcome was depression severity change from baseline to the end of the acute treatment phase, expressed as standardised effect size (Hedges' g). Meta-analyses were done using random-effects models.

FINDINGS

From 10 505 publications, 54 trials met the inclusion criteria, of which 29 (20 RCTs and nine open trials) contributed data of a maximum of 6830 participants (age range 18-85 years, male and female individuals and specific ethnicity data unavailable). More than half (4268 [62%] of 6830) of patients with major depressive disorder reported a history of childhood trauma. Despite having more severe depression at baseline (g=0·202, 95% CI 0·145 to 0·258, I2=0%), patients with childhood trauma benefitted from active treatment similarly to patients without childhood trauma history (treatment effect difference between groups g=0·016, -0·094 to 0·125, I2=44·3%), with no significant difference in active treatment effects (vs control condition) between individuals with and without childhood trauma (childhood trauma g=0·605, 0·294 to 0·916, I2=58·0%; no childhood trauma g=0·178, -0·195 to 0·552, I2=67·5%; between-group difference p=0·051), and similar dropout rates (risk ratio 1·063, 0·945 to 1·195, I2=0%). Findings did not significantly differ by childhood trauma type, study design, depression diagnosis, assessment method of childhood trauma, study quality, year, or treatment type or length, but differed by country (North American studies showed larger treatment effects for patients with childhood trauma; false discovery rate corrected p=0·0080). Most studies had a moderate to high risk of bias (21 [72%] of 29), but the sensitivity analysis in low-bias studies yielded similar findings to when all studies were included.

INTERPRETATION

Contrary to previous studies, we found evidence that the symptoms of patients with major depressive disorder and childhood trauma significantly improve after pharmacological and psychotherapeutic treatments, notwithstanding their higher severity of depressive symptoms. Evidence-based psychotherapy and pharmacotherapy should be offered to patients with major depressive disorder regardless of childhood trauma status.

FUNDING

None.

Perspectives on the success rate of current antidepressant pharmacotherapy

INTRODUCTION

There has been growing debate about the effectiveness of traditional antidepressants for the treatment of depression, and whether the clinical trials literature overstates the value of existing agents. Antidepressant efficacy is limited by suboptimal remission rates, lack of robust efficacy across diverse depressed subgroups, slow onset, and challenges managing tolerability. Clinicians can better navigate uncertainties in this area by recognizing patient-specific clinical and prognostic factors that influence the likelihood of antidepressant drug response.

AREAS COVERED

The author summarizes pertinent literature regarding drug-placebo differences in antidepressant outcome as well as patient-specific factors that influence antidepressant drug responsivity across subtypes of depressive disorders.

EXPERT OPINION

Standardized effect sizes for most monoaminergic antidepressants are relatively modest. At least one-third of treatment response derives from nonspecific (yet substantial) placebo effects, limiting the ability to compare antidepressant medication effects to that of "no treatment." Patients with high baseline depressive symptom severity are less likely to respond to placebo but may be more responsive to antidepressant pharmacotherapy than is the case in mild forms of depression. Patient satisfaction with antidepressant response must take into consideration not only efficacy for reducing symptoms but also drug tolerability/acceptability and tangible improvement in functional outcome and quality of life.

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BACKGROUND

Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.

OBJECTIVE

To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.

DESIGN

Patient self-report surveys at treatment initiation linked to medical records.

SETTING

Veterans Health Administration (VA) clinics nationally, 2018-2020.

PARTICIPANTS

A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.

KEY RESULTS

More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.

CONCLUSIONS

Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

Racial Disparities in Prescription of Antidepressants Among U.S. Veterans Referred to Behavioral Health Care

OBJECTIVE

Antidepressants are often prescribed in primary care to treat veterans who have depression. An evaluation of current racial disparities in integrated primary care is warranted. This study examined the association between race and prescription of antidepressants among veterans in primary care.

METHODS

Veterans in primary care (Black, N=4,120; White, N=4,372) who were referred from primary care to a collaborative care program completed an assessment of demographic characteristics and clinical symptoms, including of current antidepressant prescription before the referral, verified by chart review. Patient data were collected from January 1, 2015, to December 22, 2020. Logistic regression analyses were conducted to examine the relationships between patient race and both depression symptoms and antidepressant prescription. Analyses were also stratified by severity of depression symptoms to understand the results in the context of clinical guidelines.

RESULTS

White patients were almost two times (odds ratio=1.96, 95% confidence interval [CI]=1.75–2.19, p<0.001) more likely than Black patients to receive an antidepressant prescription, after the analysis was controlled for depression symptoms, demographic characteristics, and other clinical symptoms. Among patients with severe depression, for whom prescription of antidepressants is clinically indicated, White patients were 1.87 times more likely than Black patients to receive an antidepressant prescription (95% CI=1.40–2.50, p<0.001).

CONCLUSIONS

The findings reveal racial disparities in antidepressant prescription for veterans in primary care. Regular clinical review of antidepressant prescription is recommended to identify disparities in individual clinics. Future research should aim to identify drivers of racial disparities and provide recommendations for health care systems, providers, and patients.

Gut Microbiome-Linked Metabolites in the Pathobiology of Major Depression With or Without Anxiety—A Role for Bile Acids

Background

The gut microbiome may play a role in the pathogenesis of neuropsychiatric diseases including major depressive disorder (MDD). Bile acids (BAs) are steroid acids that are synthesized in the liver from cholesterol and further processed by gut-bacterial enzymes, thus requiring both human and gut microbiome enzymatic processes in their metabolism. BAs participate in a range of important host functions such as lipid transport and metabolism, cellular signaling and regulation of energy homeostasis. BAs have recently been implicated in the pathophysiology of Alzheimer's and several other neuropsychiatric diseases, but the biochemical underpinnings of these gut microbiome-linked metabolites in the pathophysiology of depression and anxiety remains largely unknown.

Method

Using targeted metabolomics, we profiled primary and secondary BAs in the baseline serum samples of 208 untreated outpatients with MDD. We assessed the relationship of BA concentrations and the severity of depressive and anxiety symptoms as defined by the 17-item Hamilton Depression Rating Scale (HRSD₁₇) and the 14-item Hamilton Anxiety Rating Scale (HRSA-Total), respectively. We also evaluated whether the baseline metabolic profile of BA informs about treatment outcomes.

Results

The concentration of the primary BA chenodeoxycholic acid (CDCA) was significantly lower at baseline in both severely depressed (log₂ fold difference (LFD) = −0.48; p = 0.021) and highly anxious (LFD = −0.43; p = 0.021) participants compared to participants with less severe symptoms. The gut bacteria-derived secondary BAs produced from CDCA such as lithocholic acid (LCA) and several of its metabolites, and their ratios to primary BAs, were significantly higher in the more anxious participants (LFD's range = [0.23, 1.36]; p's range = [6.85E-6, 1.86E-2]). The interaction analysis of HRSD₁₇ and HRSA-Total suggested that the BA concentration differences were more strongly correlated to the symptoms of anxiety than depression. Significant differences in baseline CDCA (LFD = −0.87, p = 0.0009), isoLCA (LFD = −1.08, p = 0.016) and several BA ratios (LFD's range [0.46, 1.66], p's range [0.0003, 0.049]) differentiated treatment failures from remitters.

Conclusion

In patients with MDD, BA profiles representing changes in gut microbiome compositions are associated with higher levels of anxiety and increased probability of first-line treatment failure. If confirmed, these findings suggest the possibility of developing gut microbiome-directed therapies for MDD characterized by gut dysbiosis.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

METHODS

Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

DISCUSSION

The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

A pragmatic preference trial of therapeutic yoga as an adjunct to group cognitive behaviour therapy versus group CBT alone for depression and anxiety

BACKGROUND

Yoga has several mechanisms that make it a promising treatment for depression and anxiety, including physical activity, behavioural activation, and mindfulness. Following positive outcomes from adapted CBT interventions incorporating mindfulness-based practices, this study explored the effects of a therapeutic yoga program as an adjunct to group-based CBT for depression or anxiety.

METHODS

This was a pragmatic preference trial involving adults diagnosed with depression or anxiety in a regional primary mental healthcare service (n = 59), comparing transdiagnostic group CBT (n = 27) with transdiagnostic group CBT combined with an adjunct therapeutic yoga program (n = 32). A preference recruitment design allowed eligible participants (n = 35) to self-select into the adjunct program. The Depression Anxiety Stress Scale-21 (DASS) was assessed at baseline, post-intervention, and three-months follow up.

RESULTS

CBT + Yoga was an acceptable alternative to CBT alone. Significant reductions were observed in total DASS scores and the 3 subscales of the DASS for both groups, however CBT + Yoga showed significantly lower depressive and anxiety symptoms post-intervention, compared to CBT alone. CBT + Yoga also showed sustained reductions in depressive symptoms over three-months, and more rapid reductions in depressive symptoms, compared to CBT alone.

LIMITATIONS

These findings should be considered preliminary due to the moderate sample size, with a rigorous randomised control trial necessary to definitively support the integration of yoga within mental health care to augment the benefits and uptake of transdiagnostic CBT for depression and anxiety.

CONCLUSIONS

Complementing other mindfulness-based practices, therapeutic yoga shows promise as an adjunct to transdiagnostic CBT.

Efficacy and Acceptability of Remote Cognitive Behavioral Therapy for Patients With Major Depressive Disorder in Japanese Clinical Settings: A Case Series

Remote cognitive and behavioral therapy (CBT) via videoconference has been garnering attention as a means of improving access to CBT for depression, in particular during the coronavirus disease 2019 pandemic. However, there is a lack of evidence supporting its implementation in Japanese clinical settings. This case series aimed to establish preliminary evidence of whether remote CBT can be an effective therapy for major depression in Japanese clinical settings. Five patients who met the diagnostic criteria for major depressive disorder were enrolled and underwent remote CBT via videoconference and face-to-face assessment interviews. The results showed that remote CBT via videoconference improved depressive symptoms, enabling a relatively high level of patient satisfaction and working alliance. Moreover, detailed feedback from our patients showed that continuous monitoring was preferable for increasing treatment engagement. Further research is warranted to test the efficacy and acceptability of remote CBT via videoconference for treating major depression.

Rostral anterior cingulate network effective connectivity in depressed adolescents and associations with treatment response in a randomized controlled trial

The rostral anterior cingulate cortex (rACC) is consistently implicated in the neurobiology of depression. While the functional connectivity of the rACC has been previously associated with treatment response, there is a paucity of work investigating the specific directional interactions underpinning these associations. We compared the fMRI resting-state effective connectivity of 94 young people with major depressive disorder and 91 healthy controls. Following the fMRI scan, patients were randomized to receive cognitive behavioral therapy for 12 weeks, plus either fluoxetine or a placebo. Using spectral dynamic causal modelling, we examined the effective connectivity of the rACC with eight other regions implicated in depression: the left and right anterior insular cortex (AIC), amygdalae, and dorsolateral prefrontal cortex (dlPFC); and in the midline, the subgenual (sgACC) and dorsal anterior cingulate cortex (dACC). Parametric empirical Bayes was used to compare baseline differences between controls and patients and responders and non-responders to treatment. Depressed patients demonstrated greater inhibitory connectivity from the rACC to the dlPFC, AIC, dACC and left amygdala. Moreover, treatment responders illustrated greater inhibitory connectivity from the rACC to dACC, greater excitatory connectivity from the dACC to sgACC and reduced inhibitory connectivity from the sgACC to amygdalae at baseline. The inhibitory hyperconnectivity of the rACC in depressed patients aligns with hypotheses concerning the dominance of the default mode network over other intrinsic brain networks. Surprisingly, treatment responders did not demonstrate connectivity which was more similar to healthy controls, but rather distinct alterations that may have predicated their enhanced treatment response.

Metabolomic and inflammatory signatures of symptom dimensions in major depression

BACKGROUND

Major depressive disorder (MDD) is a highly heterogenous disease, both in terms of clinical profiles and pathobiological alterations. Recently, immunometabolic dysregulations were shown to be correlated with atypical, energy-related symptoms but less so with the Melancholic or Anxious distress symptom dimensions of depression in The Netherlands Study of Depression and Anxiety (NESDA) study. In this study, we aimed to replicate these immunometabolic associations and to characterize the metabolomic correlates of each of the three MDD dimensions.

METHODS

Using three clinical rating scales, Melancholic, and Anxious distress, and Immunometabolic (IMD) dimensions were characterized in 158 patients who participated in the Predictors of Remission to Individual and Combined Treatments (PReDICT) study and from whom plasma and serum samples were available. The NESDA-defined inflammatory index, a composite measure of interleukin-6 and C-reactive protein, was measured from pre-treatment plasma samples and a metabolomic profile was defined using serum samples analyzed on three metabolomics platforms targeting fatty acids and complex lipids, amino acids, acylcarnitines, and gut microbiome-derived metabolites among other metabolites of central metabolism.

RESULTS

The IMD clinical dimension and the inflammatory index were positively correlated (r = 0.19, p = 0.019) after controlling for age, sex, and body mass index, whereas the Melancholic and Anxious distress dimensions were not, replicating the previous NESDA findings. The three symptom dimensions had distinct metabolomic signatures using both univariate and set enrichment statistics. IMD severity correlated mainly with gut-derived metabolites and a few acylcarnitines and long chain saturated free fatty acids. Melancholia severity was significantly correlated with several phosphatidylcholines, primarily the ether-linked variety, lysophosphatidylcholines, as well as several amino acids. Anxious distress severity correlated with several medium and long chain free fatty acids, both saturated and polyunsaturated ones, sphingomyelins, as well as several amino acids and bile acids.

CONCLUSION

The IMD dimension of depression appears reliably associated with markers of inflammation. Metabolomics provides powerful tools to inform about depression heterogeneity and molecular mechanisms related to clinical dimensions in MDD, which include a link to gut microbiome and lipids implicated in membrane structure and function.

Evaluating telehealth lifestyle therapy versus telehealth psychotherapy for reducing depression in adults with COVID-19 related distress: the curbing anxiety and depression using lifestyle medicine (CALM) randomised non-inferiority trial protocol

BACKGROUND

There is increasing recognition of the substantial burden of mental health disorders at an individual and population level, including consequent demand on mental health services. Lifestyle-based mental healthcare offers an additional approach to existing services with potential to help alleviate system burden. Despite the latest Royal Australian New Zealand College of Psychiatrists guidelines recommending that lifestyle is a 'first-line', 'non-negotiable' treatment for mood disorders, few such programs exist within clinical practice. Additionally, there are limited data to determine whether lifestyle approaches are equivalent to established treatments. Using an individually randomised group treatment design, we aim to address this gap by evaluating an integrated lifestyle program (CALM) compared to an established therapy (psychotherapy), both delivered via telehealth. It is hypothesised that the CALM program will not be inferior to psychotherapy with respect to depressive symptoms at 8 weeks.

METHODS

The study is being conducted in partnership with Barwon Health's Mental Health, Drugs & Alcohol Service (Geelong, Victoria), from which 184 participants from its service and surrounding regions are being recruited. Eligible participants with elevated psychological distress are being randomised to CALM or psychotherapy. Each takes a trans-diagnostic approach, and comprises four weekly (weeks 1-4) and two fortnightly (weeks 6 and 8) 90-min, group-based sessions delivered via Zoom (digital video conferencing platform). CALM focuses on enhancing knowledge, behavioural skills and support for improving dietary and physical activity behaviours, delivered by an Accredited Exercise Physiologist and Accredited Practising Dietitian. Psychotherapy uses cognitive behavioural therapy (CBT) delivered by a Psychologist or Clinical Psychologist, and Provisional Psychologist. Data collection occurs at baseline and 8 weeks. The primary outcome is depressive symptoms (assessed via the Patient Health Questionnaire-9) at 8 weeks. Societal and healthcare costs will be estimated to determine the cost-effectiveness of the CALM program. A process evaluation will determine its reach, adoption, implementation and maintenance.

DISCUSSION

If the CALM program is non-inferior to psychotherapy, this study will provide the first evidence to support lifestyle-based mental healthcare as an additional care model to support individuals experiencing psychological distress.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12621000387820 , Registered 8 April 2021.

Psychometric and Clinical Evaluation of the Clinician (VQIDS-C5) and Self-Report (VQIDS-SR5) Versions of the Very Quick Inventory of Depressive Symptoms

PURPOSE

Evaluate the psychometric properties of the 5-item Very Quick Inventory of Depressive Symptomatology self-report and clinician-rated versions (VQIDS-SR₅/VQIDS-C₅), compare their relative performance, create crosswalks between their total scores and other accepted depressive symptom ratings, and define clinically relevant depressive symptom severity thresholds and categorical outcomes for both versions.

PATIENTS AND METHODS

The Sequenced Treatment Alternatives to Relieve Depression trial obtained baseline and exit 17-item Hamilton Rating Scale for Depression (HRSD₁₇) and 30-item Inventory of Depressive Symptomatology - Clinician-rated scores, and baseline and visit-wise QIDS-SR₁₆ and QIDS-C₁₆ ratings from the first treatment step (citalopram). The VQIDS-C₅ and the VQIDS-SR₅ items (sad mood, self-outlook, involvement, fatigue, psychomotor slowing) (each rated 0-3), extracted from the corresponding 16-item ratings, were selected to best reflect the 6-item HRSD (HRSD₆) (exclusive of anxiety). Classical Test Theory (CTT) and Item-Response Theory (IRT) analyses assessed psychometric features. IRT analyses produced total score crosswalks between the VQIDS₅, QIDS-C₁₆, QIDS-SR₁₆ and HRSD₆. Clinically relevant VQIDS symptom severity thresholds and treatment outcomes were estimated based on cross-walks from the parent QIDS₁₆ ratings.

RESULTS

Both VQIDS versions were unifactorial with acceptable internal consistencies (Cronbach's alphas >0.80), item-total correlations (0.57-0.74) by CCT, and strong IRT item performance. Based on QIDS₁₆ severity thresholds (none 0-5; mild 6-10; moderate 11-15; severe 16-20; and very severe 21-27), comparable thresholds were 0-2; 3-5; 6-9; 9-12; and >12 for VQIDS-C₅, and 0-2; 2-5; 6-8; 9-12; and >12 for VQIDS-SR₅. Kappa values were acceptable in comparing categories of outcomes (eg, no benefit, remission, etc) based on VQIDS and corresponding QIDS categories.

CONCLUSION

The VQIDS-C₅ and VQIDS-SR₅ assess selected core depressive symptoms with psychometrically acceptable properties. Theelf-report and clinician-rated versions provide virtually identical information, symptom severity thresholds and symptom change categories. Both are as sensitive to change as the corresponding QIDS₁₆, making them suitable for use in busy practices.

Efficacy of exercise combined with standard treatment for depression compared to standard treatment alone: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Exercise is indicated as a monotherapy for depression, as well as an augmentation strategy alongside standard treatments. However, it is not yet clear how exercise and standard treatments interact with regards to patient outcomes. The primary aim of the current systematic review and meta-analysis was to compare the antidepressant effects of exercise combined with standard treatment to standard treatment alone.

METHOD

A systematic search was conducted for trials comparing the efficacy of standard treatments alone or in combination with exercise for reducing symptoms of depression. Random effects meta-analysis was used to estimate pooled standardized mean difference for standard treatment alone versus standard treatment with exercise.

RESULTS

Twenty-two studies were included in the meta-analysis. There was a moderate pooled effect in favour of exercise combined with standard treatment compared to standard treatment alone (SMD = -0.62, p < 0.00001, I² = 70%), with greatest benefits accruing for more severe patients (SMD = -0.99, p < 0.00001; I² = 0%). Sensitivity analyses remained significant for trials with lower risk of bias (SMD = -0.41, p = 0.0009; I² = 52%) and patients with a major depressive disorder diagnosis (SMD = -0.70, p < 0.0001; I² = 72%).

LIMITATIONS

There was considerable heterogeneity between trials. Uneven covariate distributions within subgroups limited our ability to explore the sources of heterogeneity.

CONCLUSIONS

Exercise combined with standard treatments leads to significantly greater antidepressant effects over standard treatment alone. Patients and clinicians should consider using exercise alongside standard treatments to enhance therapeutic efficacy for depression.

Yoga complements cognitive behaviour therapy as an adjunct treatment for anxiety and depression: Qualitative findings from a mixed-methods study

OBJECTIVES

Cognitive behaviour therapy (CBT) is recommended for treating anxiety and depression, demonstrating good efficacy and moderate rates of engagement. To further improve outcomes and access to evidence-based treatments, researchers have sought to enhance CBT protocols with mindfulness-based approaches, such as yoga. This study aimed to examine whether yoga is an acceptable and complementary adjunct to CBT through exploring the lived experiences of adults with anxiety and depression who engaged in an adjunct therapeutic yoga programme alongside group CBT.

DESIGN

Single-group qualitative design with post-intervention and follow-up timepoints.

METHODS

Thirty-six adults with anxiety and depression self-selected into a therapeutic yoga programme as an adjunct to group CBT. Qualitative interviews were conducted with 27 participants immediately after the eight-week programme and again three months later. Thematic analysis was used to identify common themes from the lived experiences.

RESULTS

Three primary themes, with nine subthemes, were identified which reflect the experiences of the combined therapies, the complementary elements, and process of engagement over time. The adjunct yoga programme was highly acceptable to adults with anxiety and depression, enhancing engagement and perceived outcomes. Yoga was identified as providing a unique combination of elements that complemented processes of CBT, such as behavioural activation and thought disputation. Yoga practices represented mental health self-management tools that are accessible and available as relapse prevention strategies.

CONCLUSIONS

Therapeutic yoga warrants consideration as an adjunct treatment for anxiety and depression as it offers unique and complementary elements to CBT and can enhance engagement and perceived clinical outcomes.

PRACTITIONER POINTS

Adults with anxiety and depression experienced a therapeutic yoga programme as a suitable and appealing adjunct that enhanced engagement with psychological treatment. Yoga offers a unique combination of elements, including a values system, body-based mindfulness practices, and breathing techniques, that complement CBT processes, such as behavioural activation, awareness of maladaptive patterns, and thought disputation. A therapeutic yoga programme provides adults with anxiety and depression with an accessible and sustainable mental health self-management tool. Therapeutic yoga can be considered for integration to models of mental health service provision to enhance engagement and clinical outcomes for adults with anxiety and depression.

Implicit and Explicit Beliefs About the Effectiveness of Psychotherapy vs. Medication: A Large-Scale Examination and Replication

ABSTRACT

One exploratory study (N = 10,335) and one preregistered replication and extension study (N = 6648) evaluated implicit and explicit beliefs in the effectiveness of psychotherapy versus medication, and whether these beliefs vary as a function of demographics, mental health difficulties, and treatment experiences. Data were collected from a sample of visitors to a mental health research website who completed the Therapy vs. Medication Effectiveness Implicit Association Test (IAT). The IAT demonstrated evidence of convergent validity with two measures of explicit therapy versus medication effectiveness beliefs. Across both studies, individuals held greater implicit and explicit beliefs that therapy is more effective than medication, and individuals who were Black (versus all other races, excluding "other/unknown") and who had experienced past (versus current) mental health difficulties had stronger implicit and explicit beliefs in the effectiveness of therapy versus medication. More work is needed to understand how these differences in beliefs arise, as well as to evaluate the clinical utility of this novel measure.

Indoxyl sulfate, a gut microbiome-derived uremic toxin, is associated with psychic anxiety and its functional magnetic resonance imaging-based neurologic signature

It is unknown whether indoles, metabolites of tryptophan that are derived entirely from bacterial metabolism in the gut, are associated with symptoms of depression and anxiety. Serum samples (baseline, 12 weeks) were drawn from participants (n = 196) randomized to treatment with cognitive behavioral therapy (CBT), escitalopram, or duloxetine for major depressive disorder. Baseline indoxyl sulfate abundance was positively correlated with severity of psychic anxiety and total anxiety and with resting state functional connectivity to a network that processes aversive stimuli (which includes the subcallosal cingulate cortex (SCC-FC), bilateral anterior insula, right anterior midcingulate cortex, and the right premotor areas). The relation between indoxyl sulfate and psychic anxiety was mediated only through the metabolite's effect on the SCC-FC with the premotor area. Baseline indole abundances were unrelated to post-treatment outcome measures, and changes in symptoms were not correlated with changes in indole concentrations. These results suggest that CBT and antidepressant medications relieve anxiety via mechanisms unrelated to modulation of indoles derived from gut microbiota; it remains possible that treatment-related improvement stems from their impact on other aspects of the gut microbiome. A peripheral gut microbiome-derived metabolite was associated with altered neural processing and with psychiatric symptom (anxiety) in humans, which provides further evidence that gut microbiome disruption can contribute to neuropsychiatric disorders that may require different therapeutic approaches. Given the exploratory nature of this study, findings should be replicated in confirmatory studies.Clinical trial NCT00360399 "Predictors of Antidepressant Treatment Response: The Emory CIDAR" https://clinicaltrials.gov/ct2/show/NCT00360399 .

Establishing Evidence for Clinical Utility of a Neuroimaging Biomarker in Major Depressive Disorder: Prospective Testing and Implementation Challenges

BACKGROUND

Although a number of neuroimaging biomarkers for response have been proposed, none have been tested prospectively for direct effects on treatment outcomes. To the best of our knowledge, this is the first prospective test of the clinical utility of the use of an imaging biomarker to select treatment for patients with major depressive disorder.

METHODS

Eligible participants (n = 60) had a primary diagnosis of major depressive disorder and were assigned to either escitalopram or cognitive behavioral therapy based on fluorodeoxyglucose positron emission tomography activity in the right anterior insula. The overall study remission rate after 12 weeks of treatment, based on the end point Hamilton Depression Rating Scale score, was then examined for futility and benefit of the strategy.

RESULTS

Remission rates demonstrated lack of futility at the end of stage 1 (37%, 10/27), and the study proceeded to stage 2. After adjustment for the change in stage 2 sample size, the complete remission rate did not demonstrate evidence of benefit (37.7%, 95% confidence interval, 26.3%-51.4%, p = .38). However, total remission rates (complete and partial remission) did reach significance in post hoc analysis (49.1%, 95% confidence interval, 37.6%-60.7%, p = .020).

CONCLUSIONS

The study shows some evidence for a role of the right anterior insula in the clinical choice of major depressive disorder monotherapy. The effect size, however, is insufficient for the use of insula activity as a sole predictive biomarker of remission. The study also demonstrates the logistical difficulties in establishing clinical utility of biomarkers.