Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan (PERFORM-J): Protocol for a Prospective Cohort Study

Effect of olanzapine exposure on relapse and brain structure in patients with major depressive disorder with psychotic features

Some data suggest that antipsychotics may adversely affect brain structure. We examined the relationship among olanzapine exposure, relapse, and changes in brain structure in patients with major depressive disorder with psychotic features. We analyzed data from the Study of the Pharmacotherapy of Psychotic Depression II trial (STOP-PD II), a randomized, placebo-controlled trial in patients with psychotic depression who attained remission on sertraline and olanzapine and were randomized to continue sertraline plus olanzapine or placebo for 36 weeks. Olanzapine steady state concentration (SSC) were calculated based on sparsely-sampled levels. Rates of relapse and changes in brain structure were assessed as outcomes. There were significant associations between dosage and relapse rates (N = 118; HR = 0.94, 95% CI [0.897, 0.977], p = 0.002) or changes in left cortical thickness (N = 44; B = -2.0 × 10-3, 95% CI [-3.1 × 10-3, -9.6 × 10-4], p < 0.001) and between SSC and changes in left cortical thickness (N = 44; B = -8.7 × 10-4, 95% CI [-1.4 × 10-3, -3.6 × 10-4], p = 0.001). Similar results were found for the right cortex. These associations were no longer significant when the analysis was restricted to participants treated with olanzapine. Our findings suggest that, within its therapeutic range, the effect of olanzapine on relapse or cortical thickness does not depend on its dosage or SSC. Further research is needed on the effect of olanzapine and other antipsychotics on mood symptoms and brain structure.

The mediating role of depressive symptoms and subjective cognitive dysfunction in the relationship between stressful life events and functional disability in adult community volunteers

BACKGROUND

Stressful life events (SLE) impact psychosocial functioning. However, the psychological mechanism underlying the association between SLE and functional disability (FD) has not been fully elucidated. This study focused on whether depressive symptoms (DS) and subjective cognitive dysfunction (SCD) mediated the influence of SLE, comprising negative SLE (NSLE) and positive SLE (PSLE), on FD.

METHODS

A total of 514 adults from Tokyo, Japan, completed the self-administered questionnaires to evaluate DS, SCD, SLE, and FD. We investigated the relationships among the variables using path analysis.

RESULTS

Path analyses showed that NSLE positively affected FD directly (β = 0.253, p < .001), and indirectly via DS and SCD (β = 0.192, p < .001). PSLE negatively affected FD indirectly via DS and SCD (β = -0.068, p = .010), although PSLE did not affect FD directly (β = -0.049, p = .163).

LIMITATIONS

Causal relationships could not be determined owing to the cross-sectional design. All participants were recruited in Japan, which limits the generalization of findings to other countries.

CONCLUSIONS

DS and SCD, in this order, may partially mediate the positive effect of NSLE on FD. DS and SCD may fully mediate the negative effect of PSLE on FD. When considering the impact of SLE on FD, evaluating the mediating role of DS and SCD could be useful. Our findings may elucidate how perceived life stress affects daily functioning via depressive and cognitive symptoms. In the future, it is desirable to conduct a longitudinal study based on our results.

Validation and Functional Relevance of the Short Form of the Perceived Deficits Questionnaire for Depression for Japanese Patients with Major Depressive Disorder

Purpose

To validate the five-item version of the Perceived Deficits Questionnaire for Depression (PDQ-D-5) for assessing subjective cognitive function in Japanese patients with major depressive disorder (MDD) using data from the PERFORM-J study.

Patients and Methods

A total of 518 Japanese outpatients diagnosed with MDD were assessed on severity of depressive symptoms, cognitive function, social and work function, and quality of life (QoL) over 6 months following initiation of antidepressant therapy. This post hoc analysis evaluated the internal consistency and convergent validity of the PDQ-D-5 in relation to the original PDQ-D-20. Correlations of scores on these measures were examined at each time point and over time. The same set of analyses was explored between PDQ-D-5 and the Patient Health Questionnaire-nine-item (PHQ-9), Montgomery-Asberg Depression Rating Scale (MADRS), Digit Symbol Substitution Test (DSST), five-level version of EQ-5D (EQ-5D-5L), Sheehan Disability Scale (SDS), and Work Productivity and Activity Impairment (WPAI) questionnaire.

Results

PDQ-D-5 scores showed good internal consistency. Strong positive correlations were observed between PDQ-D-5 and PDQ-D-20 at each time point (correlation coefficient: baseline, 0.94; month 1, 0.94; month 2, 0.96; month 6, 0.96) and over time (0.92) (all p < 0.0001). Longitudinally, there were positive correlations between PDQ-D-5 scores versus those on the PHQ-9, MADRS, and SDS. Similarly, negative correlations were noted between PDQ-D-5 scores and EQ-5D-5L and DSST scores to a variable degree. There were moderate positive correlations over time between PDQ-D-5 and all WPAI subscale scores except those on absenteeism.

Conclusion

PDQ-D-5 scores rated in Japanese patients with MDD were found to adequately represent scores on the PDQ-D-20. The short version also showed associations with several measures of functional outcome, depression severity and QoL. This validates the PDQ-D-5 as a feasible and clinically reliable tool to assess subjective experience on cognition, which is applicable to time-limited consultations.

UMIN Clinical Trials Registry for Primary Study

UMIN000024320.

Association between baseline cognitive symptoms and the subsequent presenteeism and global function in patients with major depressive disorder

Cognitive symptoms in major depressive disorder (MDD) contribute to impaired functional abilities and work productivity, particularly presenteeism. We investigated the association between baseline cognitive symptoms and subsequent presenteeism, and global functional impairment in Japanese patients with MDD from PERFORM-J (Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan) - a 6-month, multicenter, epidemiological study data. A total of 518 patients initiating antidepressant monotherapy (first-line or switched from another drug) were enrolled. Assessments include Perceived Deficits Questionnaire - Depression (PDQ-D) for cognitive complaints, Sheehan Disability Scale (SDS) for global function (analysed n = 318), and Work Productivity and Activity Impairment Questionnaire for presenteeism (analysed n = 122). A strong association between changes in presenteeism and changes in SDS scores (r: total = 0.636; work/school = 0.686) was observed. After adjusting for sociodemographic and MDD-related factors, patients without cognitive complaints at baseline showed lower odds of impaired presenteeism at 6 months versus patients with cognitive complaints (0.243, 95% CI: 0.079 to 0.747, p = 0.014) and also in patients with first episode of MDD against with recurrent MDD (0.327 (95% CI: 0.136 to 0.787). Similarly, patients without cognitive complaints had healthier global functioning (lower mean SDS total score) than patients with cognitive complaints (8.3 vs 11.2; 95% CI, -5.189 to -0.578; p = 0.014). First depressive episode (lower risk of presenteeism), being male, and low baseline SDS total score (better global functioning) were also associated with improved outcomes. These results highlight the potential value of baseline PDQ-D scores in predicting subsequent workplace and global functioning in patients undergoing treatment for MDD.

Health-Related Quality of Life Over 6 Months in Patients With Major Depressive Disorder Who Started Antidepressant Monotherapy

OBJECTIVES

Major depressive disorder (MDD) is increasing worldwide and is associated with impaired quality of life (QOL). This study aimed to assess the QOL and its association with cognitive symptoms in patients with MDD who started antidepressant monotherapy.

METHODS

Data from the PERFORM (Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder) study were analyzed. A descriptive epidemiological analysis on EQ-5D-5L utility score, the level of each dimension, and the EuroQoL visual analog scale value was conducted at 4 visits during 6 months' follow-up. The association between cognitive complaints and changes in QOL measures was analyzed using multivariate linear regression analysis.

RESULTS

The median EQ-5D-5L utility score improved from 0.67 at baseline to 0.82 at month 6. Although the proportion of patients reporting level 1 (no problem) in every dimension of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression increased over time, less than half of the patients achieved level 1 in pain/discomfort and depression/anxiety, which were closely related to depression and usual activities at month 6. Patients with no cognitive complaints or no history of MDD at baseline showed greater improvement in EQ-5D-5L utility scores and EuroQoL visual analog scale value for measuring QOL than those with these characteristics.

CONCLUSIONS

Treatment over 6 months improved QOL in patients with MDD although there remained room for improvement in dimensions of usual activities, pain/discomfort, and depression/anxiety. Cognitive complaints or history of MDD at baseline predicted less improvement in QOL at 6 months. Any history of MDD might delay improvement in QOL after treatment.

Prediction of residual cognitive disturbances by early response of depressive symptoms to antidepressant treatments in patients with major depressive disorder

BACKGROUND

Patients with major depressive disorder (MDD) frequently retain cognitive disturbances after recovery from mood symptoms. We investigated the relationship between early response of mood symptoms and/or remission, and residual cognitive disturbances after 6 months of antidepressant treatment.

METHODS

518 patients with MDD were followed up for 6 months after antidepressant treatment initiation (first-line or switch from a previous drug). Subjective and objective cognitive disturbances were assessed by the Perceived Deficits Questionnaire - Depression (PDQ-D) and digit symbol substitution test (DSST), respectively. Depressive symptoms, as well as remission and early response to treatment, were assessed using the Montgomery-Asberg Depression Rating Scale (MADRS). Multivariable linear and logistic regression models were used to adjust for confounders.

RESULTS

Early response of depressive mood (≥50% reduction in MADRS score at month 1) was related with fewer residual subjective cognitive symptoms, as evaluated by the PDQ-D at month 6 (p<0.001). Likewise, early remission status at month 2 was inversely associated with PDQ-D scores at month 6 (p<0.001). Among patients with baseline DSST scores of ≥1 standard deviation below the norm, early response/remission was associated with better performance on the DSST at month 6 (p<0.05).

LIMITATIONS

The cohort may not be representative of the general MDD patient population, and the possible influence of concomitant medications was not evaluated.

CONCLUSIONS

These findings suggest that early improvements in depressive symptoms predict better cognitive outcomes in patients with MDD. Grouping of patients by mood and cognition status in early stages of antidepressant treatments may facilitate efforts to improve long-term functional outcomes.

Relationship of Subjective Cognitive Impairment with Psychosocial Function and Relapse of Depressive Symptoms in Patients with Major Depressive Disorder: Analysis of Longitudinal Data from PERFORM-J

BACKGROUND

Accumulating evidence suggests the presence of cognitive impairment in patients with major depressive disorder (MDD), which affects their psychosocial function and quality of life (QoL). PERFORM-J (Prospective Epidemiological Research on Functioning Outcomes Related to MDD in Japan) is an observational, multicenter study to assess longitudinal changes in depressive symptoms, psychomotor speed, subjective cognitive function, and psychosocial function.

METHODS

Five hundred and eighteen Japanese outpatients with MDD initiating new antidepressant monotherapy (first-line or switch from previous drug) as part of their routine medical care participated in this study. Assessments at baseline and over the 6-month observation period included physician-rated depression severity (Montgomery-Åsberg Depression Rating Scale), psychomotor speed (Digit Symbol Substitution Test; DSST), subjective cognition (Perceived Deficits Questionnaire-Depression), psychosocial function (Sheehan Disability Scale), and QoL (EuroQol-5 Dimension-5 Level).

RESULTS

Antidepressant treatment for 6 months improved depressive symptoms and subjective cognitive impairment (cognitive complaints), whereas psychomotor speed remained impaired (ie, DSST total score was >1 standard deviation below the norm) in 35.6% of patients at 6 months. Impairment of subjective cognition, but not psychomotor speed at month 2 was associated with poor psychosocial function and QoL at 6 months. There was a trend for higher relapse rates at 6 months in patients with greater subjective cognitive impairment at 2 months.

CONCLUSION

These findings highlight the importance of evaluating cognitive difficulties to predict long-term outcomes in patients with MDD. Early intervention for cognitive complaints may decrease the relapse rate, which warrants further study.

C-Reactive Protein Gene Variants in Depressive Symptoms & Antidepressants Efficacy

OBJECTIVE

Although the pathogenesis of depression remains unclear, C-reactive protein (CRP) levels are commonly elevated in depressed patients. Thus, CRP single-nucleotide polymorphisms (SNPs) that influence CRP levels may be associated with depression. In the present study, we explored whether CRP SNPs are related to depressive symptoms and antidepressants efficacy in Han Chinese patients.

METHODS

We analyzed data from 440 patients with first-episode depression. We obtained genome CRP SNPs, scores of the 17-item Hamilton Rating Scale for Depression 17 (HAMD17) and its four-factor at baseline and after 6 weeks. Quantitative trait analysis was performed using UNPHASED software and curative effects were analyzed using SPSS software.

RESULTS

Male patients with SNP rs1800947G exhibited lower insomnia scores and rs2794521CC exhibited lower scores of anxiety/ physical symptoms, total HAMD17 score. Female patients with rs2794521TT exhibited higher scores of insomnia and lower antidepressants efficacy.

CONCLUSION

CRP SNPs rs1800947 and rs2794521 may be associated with depressive symptoms in patients with depression in a sexspecific fashion. Furthermore, rs2794521 may be a predictor of the efficacy of antidepressants in female patients.

Relationship of cognitive impairment with depressive symptoms and psychosocial function in patients with major depressive disorder: Cross-sectional analysis of baseline data from PERFORM-J

BACKGROUND

Evidence is accumulating for the presence of cognitive impairment in patients with major depressive disorder (MDD). The Prospective Epidemiological Research on Functioning Outcomes Related to Major Depressive Disorder in Japan (PERFORM-J) study is a 6-month, non-interventional, prospective, multicenter, epidemiological study. Using baseline data, the relationship between cognitive symptoms and psychosocial function was analyzed in Japanese patients with MDD.

METHODS

A total of 518 Japanese outpatients (aged 18-65 years) with MDD initiating new antidepressant monotherapy (first-line or switch from a previous drug) participated. Assessment measures were: physician-rated Montgomery-Asberg Depression Rating Scale (MADRS) (depression severity); Digit Symbol Substitution Test (DSST) (objective cognition); and patient-rated Perceived Deficits Questionnaire - Depression (PDQ-D) (subjective cognition); Sheehan Disability Scale (SDS); Work Productivity and Activity Impairment questionnaire (WPAI) (psychosocial function); and EuroQol-5 Dimension-5 Level (quality of life).

RESULTS

Over half of patients exhibited a greater than 1 standard deviation decline below norm in objective cognition, as measured by the DSST. Severity of depressive symptoms correlated positively with subjective (PDQ-D), but not objective (DSST) cognition. Depression severity and subjective cognition were significantly associated with psychosocial function, as measured by the SDS and WPAI (except the absenteeism items). Conversely, the association between objective cognition and psychosocial function was not significant.

LIMITATIONS

Only outpatients were recruited. Occupations and job-related stress levels were not taken into account.

CONCLUSIONS

Japanese patients with MDD presented a high incidence of cognitive impairment. The relationships between cognitive and psychosocial function in these patients suggest a need for therapeutics targeting cognitive impairment of MDD.

Assessment of current clinical practices for major depression in Japan using a web-based questionnaire

PURPOSE

To investigate the current clinical practice of Japanese physicians in the diagnosis and management of major depression (major depressive disorder [MDD]).

PATIENTS AND METHODS

Japanese physicians specializing in psychiatry or psychosomatic medicine in the medical database of Nihon Ultmarc Inc. (Chuo-Ku, Tokyo, Japan), who had treated ≥30 patients with MDD in the past month were invited to complete a web-based questionnaire from January 15 to 29, 2018. The questionnaire was comprised of 28 questions pertaining to the physician's background, the criteria and tools used to diagnose MDD during physician-patient consultation, and actual and preferred duration of physician-patient consultation. Responses were given as single answer numerical values or as multiple-choice answers.

RESULTS

From the 518 physicians invited to participate, 340 completed questionnaires were analyzed. Respondents were predominantly male (90%), hospital based (73%), affiliated with the Department of Psychiatry (95%), and members of the Japanese Society of Psychiatry and Neurology (87%). The majority of physicians (84%) agreed that "improvement of cognitive dysfunction caused by major depression is an important factor for patients to return to work" was the most challenging aspect of MDD diagnosis and management. Moreover, 83% of physicians conducted psychological assessments using a cognition evaluation test with most of their patients at the time of MDD diagnosis; the most commonly used tool was the Hasegawa Dementia Scale-Revised. Both hospital-based physicians and general practitioners would prefer to have longer consultations with their patients.

CONCLUSION

Physicians acknowledge the importance of the assessment and management of cognitive dysfunction in patients with MDD. However, most physicians would prefer to have longer consultation times with their patients for the diagnosis of MDD. In the future, it may be useful to introduce digital tools (eg, THINC-it^®) for the initial screening of cognitive dysfunction.