Patient perspectives of lithium and quetiapine augmentation treatment in treatment-resistant depression: A qualitative assessment

Clinical and cost-effectiveness of lithium versus quetiapine augmentation for treatment-resistant depression in adults: LQD a pragmatic randomised controlled trial

Background

Lithium and several atypical antipsychotics are the recommended first-line augmentation options for treatment-resistant depression; however, few studies have compared them directly, and none for longer than 8 weeks. Consequently, there is little evidence-based guidance for clinicians when choosing an augmentation option for patients with treatment-resistant depression.

Objectives

This trial examined whether it is more clinically and cost-effective to prescribe lithium or quetiapine augmentation therapy for patients with treatment-resistant depression over 12 months.

Design

This was a parallel group, multicentre, pragmatic, open-label superiority trial comparing the clinical and cost-effectiveness of lithium versus quetiapine augmentation of antidepressant medication in treatment-resistant depression. Participants were randomised 1 : 1 at baseline to the decision to prescribe either lithium or quetiapine.

Setting

Six National Health Service trusts in England.

Participants

Eligible participants were aged ≥ 18 years, met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for major depressive disorder, scored ≥ 14 on the 17-item Hamilton Depression Rating Scale and whose depression had had an inadequate response to at least two therapeutic antidepressant treatment trials in the current episode, with a current antidepressant treatment at or above the therapeutic dose for ≥ 6 weeks. Patients with a history of psychosis or bipolar disorder were excluded. Patients were judged suitable for either treatment.

Interventions

After randomisation, pre-prescribing safety checks were undertaken as per standard care and trial clinicians decided whether to proceed with prescribing the allocated medication. Trial clinicians received recommendations for titration and dosing in line with current clinical guidelines; however, dosing regimens could be altered according to tolerability and response. Participants were followed up using weekly self-report questionnaires and 8-, 26- and 52-week research visits.

Main outcome measures

The co-primary outcome measures were depressive symptom severity over 52 weeks, measured weekly using the self-rated Quick Inventory of Depressive Symptomatology, and time to all-cause treatment discontinuation of the trial medication. Economic analyses compared costs between the two treatment arms over 52 weeks, from a National Health Service and Personal Social Services perspective, and a societal perspective.

Results

Two hundred and twelve participants were randomised, 107 to quetiapine and 105 to lithium. The quetiapine arm showed a significantly greater reduction in depressive symptoms than the lithium arm over 52 weeks (quetiapine vs. lithium area under the differences curve = -68.36, 95% confidence interval: -129.95 to -6.76, p = 0.0296). Median days to discontinuation did not significantly differ between the two arms (quetiapine = 365.0, interquartile range = 57.0-365.0, lithium = 212.0, interquartile range = 21.0-365.0), p = 0.1196. Quetiapine was more cost effective than lithium. Thirty-two serious adverse events were recorded, only one of which was deemed possibly related to the intervention (lithium).

Limitations

The trial was unblinded, therefore expectancies regarding the trial medications may have influenced the results. Further, there was substantial missing data for some of the secondary outcome measures.

Conclusions

As well as being more cost-effective, quetiapine may be a more clinically effective augmentation option for treatment-resistant depression.

Future work

Examining predictors of treatment response, including clinical, sociodemographic and biological factors, will help establish whether there are additional factors to consider when choosing an augmentation treatment for treatment-resistant depression.

Trial registration

This trial is registered as ISRCTN16387615.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/222/02) and is published in full in Health Technology Assessment; Vol. 29, No. 12. See the NIHR Funding and Awards website for further award information.

A Survey Exploring People's Experiences With Lithium Bought as a Supplement: Une enquête sur l'expérience des personnes avec le lithium en supplément

ObjectiveLithium, despite its evidence base and range of indications, is often underutilized due to safety concerns associated with high-dose prescriptions and consequent necessity for regular blood monitoring. Emerging evidence suggests its potential benefits at lower doses, especially for its pro-cognitive effects and positive safety profile. While accessible as a supplement, empirical human evidence on neuropsychiatric effects is lacking. This study aimed to provide preliminary evidence regarding the utilization and perceived effects of low-dose lithium supplements (LiS) in the community.MethodsCross-sectional, opportunistic survey of 211 participants aged ≥18 years who disclosed taking over-the-counter lithium supplements. The survey assessed sample demographics, supplement details, overall perspectives, and personal experiences related to the use of LiS.ResultsThe most common form of LiS taken was aspartate at 10 mg once per day, although lithium orotate and ionic lithium were also frequently used. The most common beliefs regarding the benefits of using lithium as a supplement concern efficacy for anxiety, but the most common improvements experienced was in the domain of cognition, closely followed by anxiety and mood. Mood was most commonly reported as the greatest improvement. Side effects and withdrawal phenomena were more prevalent than anticipated.ConclusionThis study revealed a diverse range of lithium supplements taken, in terms of dosage, formulation, frequency, and duration of intake. Anecdotal evidence highlighted prevalent perceived benefits and adverse effects. The study is, however, limited notably by its cross-sectional opportunistic design; more robust evidence, especially from controlled trials, is needed to fully establish the specific benefits and drawbacks associated with different forms and doses of accessible lithium supplements.Plain Language Summary TitleA survey exploring people's experiences with lithium bought as a supplement.Plain Language SummaryLithium is the oldest effective medication used in psychiatry and holds an important place today. However, there are challenges with lithium in high doses and it may still be effective in low doses. Lower doses of lithium can be bought as a supplement over the counter, but this version of lithium has not been studied in research. We did a survey aiming to tell us some information about the experiences of people who have taken this supplementary lithium ("LiS"). From 211 adults who completed our study, results suggested that LiS is taken in many different forms, at different doses, frequencies and for different durations. People commonly believed and/or found that LiS was beneficial for anxiety, mood and cognition. Side effects and symptoms after stopping LiS were, however, more common than expected. Because this was just an initial survey, more in depth and rigorous research studies are needed to fully understand the exact benefits and drawbacks associated with different forms and doses of accessible lithium supplements.

Quantitative evaluation of multiple treatment regimens for treatment-resistant depression

OBJECTIVE

This study aims to quantitatively evaluate the efficacy and safety of various treatment regimens for treatment-resistant depression (TRD) across oral, intravenous, and intranasal routes to inform clinical guidelines.

METHODS

A systematic review identified randomized controlled trials on TRD, with efficacy measured by changes in the Montgomery-Åsberg Depression Rating Scale (MADRS). We developed pharmacodynamic and covariate models for different administration routes, using Monte Carlo simulations to estimate efficacy distribution. Dropout and adverse event-related dropout rates were analyzed via single-arm meta-analysis.

RESULTS

Involving 22 studies with 56 treatment arms and 3059 patients, our findings suggest combination therapies outperform monotherapy, achieving an additional 6.5% reduction in MADRS scores over 12 weeks. The most effective combinations were olanzapine with fluoxetine and quetiapine with selective serotonin reuptake inhibitors/ selective serotonin and norepinephrine reuptake inhibitors. Injectable treatments, particularly ayahuasca, produced rapid effects, with a 77% reduction in MADRS scores at 15 days. Intranasal treatments reached efficacy sooner than oral ones, with 28-day efficacy similar to the 12-week efficacy of the olanzapine-fluoxetine combination. Dropout rates due to adverse events were similar across methods (4.5%-5.2%), but total dropouts were highest for oral (17.9%) and lowest for intranasal routes (10.6%). Additionally, there was considerable variation in the incidence of headache, dizziness, and nausea across different administration routes.

CONCLUSIONS

The quantitative evaluation of 22 TRD treatments illuminates key pharmacodynamic parameters, bolstering the development of clinical guidelines and aiding the design of clinical trials and medical decision-making.

Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.