Development of a family functioning scale for major depressive disorder

Translation, Cultural Adaptation, and Psychometric Validation of the European Portuguese Version of the Iceland-Expressive Family Functioning Questionnaire (ICE-EFFQ)

A family's experience of mental illness can change the family's functioning. In clinical contexts, valid and reliable instruments that assess family functioning, therapeutic changes, and the effects of family nursing interventions are needed. This study focuses on the linguistic and cultural adaptation of the Iceland-Expressive Family Functioning Questionnaire (ICE-EFFQ) to European Portuguese and examines the psychometric properties of this instrument. A non-random sample of 121 Portuguese depressed patients and their relatives completed the questionnaire. Principal components analysis extracted 4 factors, explaining 55.58% of the total variance. Confirmatory factor analysis revealed acceptable adjustment quality indices. Cronbach's alpha coefficient was adequate for the global scale α = .86 and for the 4 subscales: communication α = .79, expression of emotions α = .68, problem-solving α = .71, and cooperation α = .61. The Portuguese version of ICE-EFFQ is a sensitive, valid, and reliable instrument for use with Portuguese families with adult members with depression and can be valuable in assessing these families' expressive functioning, before and after intervention.

The lived experience of major and treatment-resistant depression in England: a mixed-methods study

INTRODUCTION

Major depressive disorder (MDD) is a common, frequently recurrent condition associated with decreased well-being and increased healthcare-related costs. Mixed-methods research provides multiple ways of illustrating the phenomenon to better understand patient experience, including where treatment is not working, referred to here as treatment-resistant depression (TRD).

METHODS

A mixed-methods study investigated the experiences of people with symptomatic MDD, symptomatic TRD or TRD in remission, surveying 148 adults recruited from English clinical sites to measure symptom severity (Patient Health Questionnaire-9 [PHQ-9]), HRQoL (EQ-5D-5L/World Health Organisation Brief Assessment of QoL [WHOQOL-BREF]) and work productivity/activity impairment (WPAI:D). Interviews with 26 survey respondents were analysed thematically. Integrated datasets explored areas of convergence and divergence, with concepts mapped against the EQ-5D-5L.

RESULTS

Qualitative data explained low WHOQOL-BREF domain scores and the interrelation of psychological, emotional, cognitive and physical difficulties. Tiredness, lack of energy and motivation impacted daily activities, socialising and career goals. Low work performance scores were explained by poor concentration, decision-making and motivation. Participants also described the influence of social support and housing insecurity. Only 19 % of HRQoL qualitative codes mapped to the EQ-5D-5L. Themes dominant in patients with TRD were inability to cope, self-care challenges, dissatisfaction with mental health services and treatment pessimism.

LIMITATIONS

Limited data collected on people with TRD in remission.

CONCLUSIONS

The EQ-5D-5L and WPAI:D likely underestimate how depression impacts the HRQoL and work of people with MDD or TRD. Qualitative data suggest increased distress for people with TRD compared to those with MDD. Clinical management and treatment access decisions should consider the broader impacts of depression and environmental factors affecting the patient's experience.

Vortioxetine in patients with major depressive disorder and high levels of anxiety symptoms: An updated analysis of efficacy and tolerability

BACKGROUND

Patients with major depressive disorder (MDD) often experience comorbid anxiety symptoms. Vortioxetine has demonstrated efficacy in treating anxiety symptoms in patients with MDD; however, efficacy and tolerability have not been assessed across the entire approved dosage range.

METHODS

The efficacy and tolerability of vortioxetine 5-20 mg/day were assessed in patients with MDD and high levels of anxiety symptoms (Hamilton Anxiety Rating Scale [HAM-A] total score ≥ 20) using pooled data from four randomized, fixed-dose, placebo-controlled studies (n = 842). Data from a randomized, double-blind study of vortioxetine 10-20 mg/day versus agomelatine 25-50 mg/day in patients with an inadequate response to prior therapy (n = 299) were analyzed separately. Mean changes from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS), HAM-A, and Sheehan Disability Scale (SDS) total scores were analyzed by vortioxetine dosage.

RESULTS

The pooled analysis of fixed-dose studies demonstrated a clear dose-response relationship for vortioxetine 5-20 mg/day for improvements in MADRS, HAM-A, and SDS total scores. Vortioxetine 20 mg/day demonstrated significant effects versus placebo from week 4 onwards. In the post-hoc analysis of the active-controlled study in patients with an inadequate response to prior therapy, vortioxetine 10-20 mg/day was superior to agomelatine across all outcome measures from week 4 onwards. Up-titration of vortioxetine to 20 mg/day was not associated with an increase in adverse events.

LIMITATIONS

Short-term trials.

CONCLUSIONS

Vortioxetine is efficacious and well tolerated in patients with MDD and high levels of anxiety symptoms, including those with an inadequate response to prior therapy. The greatest therapeutic benefits were observed with vortioxetine 20 mg/day.

TRIAL REGISTRATION

NCT01140906, NCT01153009, NCT01163266, NCT01255787, NCT01488071.

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 mixed method evaluation of an intervention for parents with mental illness

Let's Talk About Children is a manualised intervention for parents with a mental illness that aims to impact positively on family dynamics. Previous evaluations focused on parents with an affective disorder. The purpose of this study was to evaluate the intervention for parents with various mental illnesses and explore parents' self-reported views regarding the impact of the intervention. A quasi-experimental approach was employed to compare outcomes for parents who received Let's Talk About Children plus treatment as usual (n = 20) with a wait list control (treatment as usual) group (n = 19), using family functioning and parenting stress questionnaires. Questionnaires were completed 2 weeks prior to receiving the intervention and 4 to 6 weeks after the final session. The wait list parents completed the same questionnaires at two time periods, 6 weeks apart. Semi-structured interviews were conducted after the intervention. Both intervention and control groups showed improvements in parenting and family functioning. Interview data highlighted (1) increased insight, (2) normalising of the illness in the family, (3) family communication changes, (4) the importance of supporting the parenting role and (5) suggestions for additional supports. There are possible issues regarding the influence of psycho-education when giving participants information about the nature of the research.

Family functioning and 1-year prognosis of first-episode major depressive disorder

This study aims at investigating the characteristics of family functioning in Chinese first-episode major depressive disorder (FE-MDD) patients and its relationship with major depressive episode (MDE) duration. We recruited 63 FE-MDD families and 59 healthy comparison (HC) families from WuHan Mental Health Center and its nearby communities from September 2014 to August 2016. Family functioning was assessed by the Chinese version of Family Assessment Device (FAD). After baseline assessment, MDD patients were followed-up monthly for one year. Independent t test and Pearson correlation analysis were respectively used to compare the family functioning of MDD and HC families and to assess the relationship between family functioning and MDE duration. Our results showed that MDD families exhibited family impairment in all the 7 sub-scales of FAD. MDD patients with "healthy family functioning" showed significantly shorter MDE duration than those with "unhealthy family functioning". MDE duration was positively correlated with the score of problem solving (PS), communication (CM) and general functioning (GF) subscales. These findings indicate that Chinese MDD families are associated with a wide range of family impairments and family functioning is linked to the MDE duration. Improvement of family functioning may be helpful for the recovery of MDD.

The impact of antidepressant treatments on family functioning in adults with major depressive disorder: a post hoc comparison of vortioxetine and agomelatine

OBJECTIVE

There is limited research on the impact of antidepressant treatment on family functioning. This study examines the impact of vortioxetine and agomelatine on family functioning using the Depression and Family Functioning Scale (DFFS).

METHODS

The DFFS was included in REVIVE, a randomized, double-blind study of adults with major depressive disorder with inadequate response to antidepressant treatment who switched to vortioxetine or agomelatine. The prespecified DFFS analyses were performed using change from baseline to weeks 8 and 12, analyzed by mixed models for repeated measurements by treatment groups. Post hoc analyses compared DFFS scores for remitters and nonremitters. Patients were stratified into quartiles using DFFS scores, and scores on other clinical outcome assessments were compared.

RESULTS

Sizeable improvements in DFFS scores were observed from baseline to week 8 (-10.8, -7.9 for vortioxetine and agomelatine, respectively), with further improvements at week 12 (-13.5, -11.0). Vortioxetine (n = 189) was superior to agomelatine (n = 187) by 2.9 DFFS points at week 8 (p < .01) and 2.5 points at week 12 (p < .05), and DFFS item-level improvements were also significantly greater for vortioxetine for 8 of 15 DFFS items at week 8 and 7 items at week 12. At week 8, remitters (n = 142) and nonremitters (n = 233) differed by 11 DFFS points; at week 12, remitters (n = 183) and nonremitters (n = 121) differed by almost 12 DFFS points. Patients stratified into baseline DFFS quartiles showed trends on clinical outcomes such that better family functioning was associated with better functional status and depressive symptoms.

CONCLUSIONS

Vortioxetine was significantly superior to agomelatine in terms of family functioning and partner relationships, as well as social functioning, health status, and depression symptoms at weeks 8 and 12. Depressed patients with impaired family functioning showed worse overall functioning, health status, and depression symptoms, suggesting that more attention should be given to family functioning of depressed patients.

Psychometric validation of the depression and family functioning scale

OBJECTIVE

A new patient-reported outcome (PRO) measure developed to assess the impact of major depressive disorder (MDD) on partner and family interactions and quality of relationships, the Depression and Family Functioning Scale (DFFS), was analyzed to establish its reliability, validity, and responsiveness.

METHODS

Data from a multi-center, prospective, 2-year observational study were analyzed to assess the psychometric properties of the DFFS in patients with MDD (nBaseline = 478; nMonth2 = 433). Measures administered to assess validity included the Sheehan Disability Scale (SDS), Arizona Sexual Experiences Scale (ASEX) and Short Form Health Survey-12 (SF-12). Reliability (Cronbach's alphas and intra-class correlations), construct validity (factor analysis and correlations), discriminating ability (analyses of variance), and responsiveness (standardized effect size estimates) were evaluated.

RESULTS

Principal components analyses indicated a single underlying dimension, confirmed by highly satisfactory Cronbach's alphas (αBaseline = 0.85, αMonth2 = 0.89). The DFFS demonstrated satisfactory test-re-test reliability in patients with the same SDS family life/home responsibilities ratings at baseline and month 2 (intraclass correlation = 0.75). Correlations with other measures showed convergent and divergent validity; e.g., the DFFS correlated better with SF-12 mental component scores (rBaseline = -0.35, rMonth2 = -0.49) than with SF-12 physical component scores (rBaseline = -0.05, rMonth2 = -0.31). Hypothesis tests were generally as predicted; many were statistically significant, substantiating DFFS discriminating ability. Standardized effect size estimates of responsiveness ranged from 0.44-0.84, demonstrating that the items were capable of detecting change.

CONCLUSIONS

The psychometric analyses support the reliability, validity, and responsiveness of the DFFS and its usefulness for assessing the impact of depression on family functioning. The DFFS can potentially provide important information not captured in clinical practice and facilitate more comprehensive evaluation of MDD treatments.

A randomised, double-blind study in adults with major depressive disorder with an inadequate response to a single course of selective serotonin reuptake inhibitor or serotonin-noradrenaline reuptake inhibitor treatment switched to vortioxetine or agomelatine

OBJECTIVE

This randomised, double-blind, 12-week study compared efficacy and tolerability of flexible-dose treatment with vortioxetine(10-20 mg/day) versus agomelatine (25-50 mg/day) in major depressive disorder patients with inadequate response to selective serotonin reuptake inhibitor (SSRI)/serotonin-noradrenaline reuptake inhibitor (SNRI) monotherapy.

METHODS

Patients were switched directly from SSRI/SNRI to vortioxetine or agomelatine. Primary endpoint was change from baseline to week 8 in the Montgomery-Åsberg Depression Rating Scale (MADRS) total score analysed by mixed model for repeated measurements, using a noninferiority test followed by a superiority test. Secondary endpoints included response and remission rates, anxiety symptoms(Hamilton Anxiety Rating Scale), Clinical Global Impression, overall functioning (Sheehan Disability Scale), health-related quality of life(EuroQol 5 Dimensions), productivity (work limitation questionnaire) and family functioning (Depression and Family Functioning Scale).

RESULTS

Primary endpoint noninferiority was established and vortioxetine (n = 252) was superior to agomelatine (n = 241) by 2.2 MADRS points (p<0.01). Vortioxetine was also significantly superior in response and remission rates at weeks 8 and 12; MADRS, Hamilton Anxiety Rating Scale, Clinical Global Impression, Sheehan Disability Scale and EuroQol 5 Dimensions scores at week 4 onwards; work limitation questionnaire at week 8 and Depression and Family Functioning Scale at weeks 8 and 12. Fewer patients withdrew because of adverse events with vortioxetine (5.9% vs 9.5%). Adverse events (incidence ≥5%) were nausea, headache, dizziness and somnolence.

CONCLUSIONS

Vortioxetine was noninferior and significantly superior to agomelatine in major depressive disorder patients with previous inadequate response to a single course of SSRI/SNRI monotherapy. Vortioxetine was safe and well tolerated.