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Fava GA, Cosci F, Guidi J, Rafanelli C. The Deceptive Manifestations of Treatment Resistance in Depression: A New Look at the Problem. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 89:265-273. [PMID: 32325457 DOI: 10.1159/000507227] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/11/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Jenny Guidi
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Chiara Rafanelli
- Department of Psychology, University of Bologna, Bologna, Italy,
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Bergfeld IO, Mantione M, Figee M, Schuurman PR, Lok A, Denys D. Treatment-resistant depression and suicidality. J Affect Disord 2018; 235:362-367. [PMID: 29665520 DOI: 10.1016/j.jad.2018.04.016] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/28/2018] [Accepted: 04/02/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Thirty percent of patients with treatment-resistant depression (TRD) attempt suicide at least once during their lifetime. However, it is unclear what the attempted and completed suicide incidences are in TRD patients after initiating a treatment, and whether specific treatments increase or decrease these incidences. METHODS We searched PubMed systematically for studies of depressed patients who failed at least two antidepressant therapies and were followed for at least three months after initiating a treatment. We estimated attempted and completed suicide incidences using a Poisson meta-analysis. Given the lack of controlled comparisons, we used a meta-regression to estimate whether these incidences differed between treatments. RESULTS We included 30 studies investigating suicidality in 32 TRD samples, undergoing deep brain stimulation (DBS, n = 9), vagal nerve stimulation (VNS, n = 9), electroconvulsive therapy (ECT, n = 5), treatment-as-usual (n = 3), capsulotomy (n = 2), cognitive behavioral therapy (n = 2), ketamine (n = 1), and epidural cortical stimulation (n = 1). The overall incidence of completed suicides was 0.47 per 100 patient years (95% CI: 0.22-1.00), and of attempted suicides 4.66 per 100 patient years (95% CI: 3.53-6.23). No differences were found in incidences following DBS, VNS or ECT. LIMITATIONS Suicidality is poorly recorded in many studies limiting the number of studies available. CONCLUSIONS The completed and attempted suicide incidences are high (0.47 and 4.66 per 100 patient years respectively), but these incidences did not differ between three end of the line treatments (DBS, VNS or ECT). Given the high suicide risk in TRD patients, clinical trials should consider suicidality as an explicit outcome measure.
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Affiliation(s)
- Isidoor O Bergfeld
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Brain and Cognition, Amsterdam, The Netherlands.
| | - Mariska Mantione
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn Figee
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Brain and Cognition, Amsterdam, The Netherlands; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - P Richard Schuurman
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Anja Lok
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Brain and Cognition, Amsterdam, The Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Brain and Cognition, Amsterdam, The Netherlands; Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, the Netherlands
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Balestri M, Calati R, Souery D, Kautzky A, Kasper S, Montgomery S, Zohar J, Mendlewicz J, Serretti A. Socio-demographic and clinical predictors of treatment resistant depression: A prospective European multicenter study. J Affect Disord 2016; 189:224-32. [PMID: 26451508 DOI: 10.1016/j.jad.2015.09.033] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/02/2015] [Accepted: 09/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few studies investigated socio-demographic and clinical predictors of non response and remission in treatment resistant depression (TRD) in the case of failure of more than two adequate antidepressant (AD) trial. The primary aim of this study was to investigate socio-demographic and clinical predictors of TRD defined as the lack of response to at least three adequate AD treatments, two of which prospectively evaluated. As secondary aims, we also investigated predictors of non response and remission to: (1) at least two adequate AD treatment (one of which prospectively assessed); (2) at least one adequate and retrospectively assessed AD treatment. METHODS In the context of a European multicenter project, 407 major depressive disorder (MDD) patients who failed to respond to a previous AD treatment were recruited for a 2 stage trial, firstly receiving venlafaxine and then escitalopram. MINI, HRSD, MADRS, UKU, CGI-S and CGI-I were administered. RESULTS Ninety eight subjects (27.61%) were considered as resistant to three AD treatments. Clinical predictors were: longer duration and higher severity of the current episode (p=0.004; ES=0.24; p=0.01; RR=1.41, respectively), outpatient status (p=0.04; RR=1.58), higher suicidal risk level (p=0.02; RR=1.49), higher rate of the first/second degree psychiatric antecedents (MDD and others) (p=0.04; RR=1.31, p=0.03; RR=1.32 respectively) and side effects during treatments (p=0.002; RR=2.82). Multivariate analyses underlined the association between TRD and the severity of the current episode (p=0.04). As for secondary outcomes, predicting factors were partially overlapping. LIMITATIONS The limited sample size and specific drugs used limit present findings. CONCLUSION Subjects with a high degree of resistance to AD treatments show specific features which may guide the clinicians to the choice of more appropriate therapies at baseline.
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Affiliation(s)
- Martina Balestri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123 Bologna, Italy
| | - Raffaella Calati
- INSERM U1061, University of Montpellier, FondaMental Foundation, Montpellier, France
| | - Daniel Souery
- Laboratoire de Psychologie Médicale, Université Libre de Bruxelles, and Centre Européen de Psychologie Médicale-PsyPluriel, Brussels, Belgium
| | - Alexander Kautzky
- Medical University of Vienna, Department of Psychiatry and Psychotherapy, Vienna, Austria
| | - Siegfried Kasper
- Medical University of Vienna, Department of Psychiatry and Psychotherapy, Vienna, Austria
| | | | - Joseph Zohar
- Chaim Sheba Medical Center, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123 Bologna, Italy.
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IsHak WW, Mirocha J, Pi S, Tobia G, Becker B, Peselow ED, Cohen RM. Patient-reported outcomes before and after treatment of major depressive disorder. DIALOGUES IN CLINICAL NEUROSCIENCE 2015. [PMID: 25152656 PMCID: PMC4140511 DOI: 10.31887/dcns.2014.16.2/rcohen] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patient reported outcomes (PROs) of quality of life (QoL), functioning, and depressive symptom severity are important in assessing the burden of illness of major depressive disorder (MDD) and to evaluate the impact of treatment. We sought to provide a detailed analysis of PROs before and after treatment of MDD from the large Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. This analysis examines PROs before and after treatment in the second level of STAR*D. The complete data on QoL, functioning, and depressive symptom severity, were analyzed for each STAR*D level 2 treatment. PROs of QoL, functioning, and depressive symptom severity showed substantial impairments after failing a selective serotonin reuptake inhibitor trial using citalopram (level 1). The seven therapeutic options in level 2 had positive statistically (P values) and clinically (Cohen's standardized differences [Cohen's d]) significant impact on QoL, functioning, depressive symptom severity, and reduction in calculated burden of illness. There were no statistically significant differences between the interventions. However, a substantial proportion of patients still suffered from patient-reported QoL and functioning impairment after treatment, an effect that was more pronounced in nonremitters. PROs are crucial in understanding the impact of MDD and in examining the effects of treatment interventions, both in research and clinical settings.
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Affiliation(s)
- Waguih William IsHak
- Vice Chairman for Education & Research and Consultant Psychiatrist, Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences, Los Angeles, California, USA; Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences, Los Angeles, California, USA; David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - James Mirocha
- Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences, Los Angeles, California, USA
| | - Sarah Pi
- Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences, Los Angeles, California, USA
| | - Gabriel Tobia
- Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences, Los Angeles, California, USA
| | - Bret Becker
- Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences, Los Angeles, California, USA
| | - Eric D Peselow
- Richmond University Medical Center and Freedom From Fear, Staten Island, New York, USA
| | - Robert M Cohen
- Department of Psychiatry, Emory University School of Medicine
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Munshi K, Eisendrath S, Delucchi K. Preliminary long-term follow-up of Mindfulness-based cognitive therapy-induced remission of depression. Mindfulness (N Y) 2012; 4:354-361. [PMID: 24443660 DOI: 10.1007/s12671-012-0135-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Major depressive disorder (MDD) is often chronic and characterized by relapse and recurrence despite successful treatments to induce remission. Mindfulness-based cognitive therapy (MBCT) was developed as a means of preventing relapse for individuals in remission using cognitive interventions. In addition, MBCT has preliminarily been found to be useful in treating active depression. This current investigation is unique in evaluating the long-term outcome of individuals with active depression who achieved remission with MBCT. 18 participants who achieved remission after an 8-week MBCT group were seen for evaluation at a mean follow-up interval of 48.7 months (SD=10.2) after completing treatment. The current study shows that in these participants, the gains achieved after the initial treatment including remission of depression, decreased rumination, decreased anxiety, and increased mindfulness continued for up to 58.9 months of follow-up. The data suggests that all levels of depression from less recurrent and mild to more recurrent and severe were responsive to MBCT. The average number of minutes per week of continued practice in our cohort was 210, but the number of minutes of practice did not correlate with depression outcomes. MBCT's effects may be more related to regularity of practice than specific quantity. This study provides a preliminary exploration of MBCT's long-term effects, which can aid in future research with a typically chronic illness.
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Affiliation(s)
- Krishna Munshi
- Department of Psychiatry, UCSF Medical Center, 401 Parnassus Avenue, San Francisco, CA, 859-248-1524
| | - Stuart Eisendrath
- Department of Psychiatry, UCSF Medical Center, 401 Parnassus Avenue, San Francisco, CA, 415-476-7868
| | - Kevin Delucchi
- Department of Psychiatry, UCSF Medical Center, 401 Parnassus Avenue, San Francisco, CA, 415-864-7220
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Mirabel-Sarron C. Thérapies comportementales et cognitives et troubles de l’humeur. ANNALES MEDICO-PSYCHOLOGIQUES 2011. [DOI: 10.1016/j.amp.2011.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Holtzheimer PE, Mayberg HS. Stuck in a rut: rethinking depression and its treatment. Trends Neurosci 2010; 34:1-9. [PMID: 21067824 DOI: 10.1016/j.tins.2010.10.004] [Citation(s) in RCA: 219] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 10/10/2010] [Accepted: 10/12/2010] [Indexed: 02/09/2023]
Abstract
The current definition of major depressive disorder (MDD) emerged from efforts to create reliable diagnostic criteria for clinical and research use. However, despite decades of research, the neurobiology of MDD is largely unknown, and treatments are no more effective today than they were 50-70 years ago. Here, we propose that the current conception of depression is misguiding basic and clinical research. Redefinition is necessary and could include a focus on a more narrowly defined set of core symptoms. However, we conclude that depression is better defined as the tendency to enter into, and inability to disengage from, a negative mood state rather than the mood state per se. We also discuss the implications of this revised definition for future clinical and basic research.
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Affiliation(s)
- Paul E Holtzheimer
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 101 Woodruff Circle NE, Suite 4000, Atlanta, GA 30322, USA.
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Holtzheimer PE. Advances in the Management of Treatment-Resistant Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2010; 8:488-500. [PMID: 25960694 DOI: 10.1176/foc.8.4.foc488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Treatment-resistant depression (TRD) is a prevalent, disabling, and costly condition affecting 1%-4% of the U.S. POPULATION Current approaches to managing TRD include medication augmentation (with lithium, thyroid hormone, buspirone, atypical antipsychotics, or various antidepressant medications), psychotherapy, and ECT. Advances in understanding the neurobiology of mood regulation and depression have led to a number of new potential approaches to managing TRD, including medications with novel mechanisms of action and focal brain stimulation techniques. This review will define and discuss the epidemiology of TRD, review the current approaches to its management, and then provide an overview of several developing interventions.
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Affiliation(s)
- Paul E Holtzheimer
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Abstract
Cognitive behavioral therapy (CBT) and pharmacotherapy are each efficacious for generalized anxiety disorder (GAD). It is not known, however, whether GAD partial and nonresponders to one treatment modality benefit from the other. This study explored acceptability and efficacy of escitalopram for persons with persistent GAD symptoms after a course of CBT. Twenty-four patients with GAD were treated with CBT and 15 completed at least 12 sessions. Eight completers continued to have clinically significant symptoms and were offered 12 weeks of treatment with escitalopram, and 7 started escitalopram treatment. During CBT, patients evidenced significant improvement in GAD, depression, and quality of life. During escitalopram treatment, patients evidenced trends toward further improvement in GAD, depression, and quality of life. Escitalopram phase completers had initially reported low-to-moderate preferences for medication treatment. Escitalopram may benefit GAD patients with clinically significant symptoms after CBT and merits further study under controlled conditions in a larger sample.
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Abstract
The sequential model of treatment for depression, i.e. the use of psychotherapy in patients who have remitted from a major depressive disorder after a course of pharmacotherapy, is an intensive two-stage approach that derives from the awareness that one course of treatment is unlikely to provide a solution to all the symptoms of patients. The aim of the sequential approach is to provide different types of treatment for as long as considered necessary in different phases of illness as determined by repeated assessments. The treatment strategies are chosen on the basis of the symptoms identified and not as predefined options. The sequential model emphasizes consideration of subclinical and residual symptomatology according to the organizing principles of macro-analysis (a relationship between co-occurring symptoms and problems is established on the basis of where treatment should commence in the first place). Diagnostic endpoints (i.e. DSM diagnoses), the customary guidance of treatment planning, are replaced by conceptualization of disorders as 'transfer stations', which are amenable to longitudinal verification and modification. The aim of this systematic review was to survey the literature concerned with the sequential approach to the treatment of depression. Randomized controlled trials were identified using MEDLINE and a manual search of the literature. In seven of the eight studies that were identified, the sequential use of pharmacotherapy and psychotherapy was found to improve long-term outcome after termination of treatment compared with clinical management and treatment as usual. Nevertheless, data on this approach are limited and more studies are necessary for detailing the various clinical steps associated with it. The sequential approach calls for a re-assessment of the design of comparative clinical trials. It allows randomization of patients who are already in treatment and assignment of them to treatment alternatives according to stages of development of their illness and not simply to disease classification. The model is thus more in line with the chronicity of mood disorders compared to the standard randomized controlled trial, which is based on the acute disease model.
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Affiliation(s)
- Giovanni A Fava
- Affective Disorders Program and Laboratory of Experimental Psychotherapy, Department of Psychology, University of Bologna, Bologna, Italy.
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Matsunaga M, Okamoto Y, Suzuki SI, Kinoshita A, Yoshimura S, Yoshino A, Kunisato Y, Yamawaki S. Psychosocial functioning in patients with Treatment-Resistant Depression after group cognitive behavioral therapy. BMC Psychiatry 2010; 10:22. [PMID: 20230649 PMCID: PMC2856539 DOI: 10.1186/1471-244x-10-22] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Accepted: 03/16/2010] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although patients with Treatment Resistant Depression (TRD) often have impaired social functioning, few studies have investigated the effectiveness of psychosocial treatment for these patients. We examined whether adding group cognitive behavioral therapy (group-CBT) to medication would improve both the depressive symptoms and the social functioning of patient with mild TRD, and whether any improvements would be maintained over one year. METHODS Forty-three patients with TRD were treated with 12 weekly sessions of group-CBT. Patients were assessed with the Global Assessment of Functioning scale (GAF), the 36-item Short-Form Health Survey (SF-36), the Hamilton Rating Scale for Depression (HRSD), the Dysfunctional Attitudes Scale (DAS), and the Automatic Thought Questionnaire-Revised (ATQ-R) at baseline, at the termination of treatment, and at the 12-month follow-up. RESULTS Thirty-eight patients completed treatment; five dropped out. For the patients who completed treatment, post-treatment scores on the GAF and SF-36 were significantly higher than baseline scores. Scores on the HRSD, DAS, and ATQ-R were significantly lower after the treatment. Thus patients improved on all measurements of psychosocial functioning and mood symptoms. Twenty patients participated in the 12-month follow-up. Their improvements for psychosocial functioning, depressive symptoms, and dysfunctional cognitions were sustained at 12 months following the completion of group-CBT. CONCLUSIONS These findings suggest a positive effect that the addition of cognitive behavioural group therapy to medication on depressive symptoms and social functioning of mildly depressed patients, showing treatment resistance.
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Affiliation(s)
- Miki Matsunaga
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan,Department of Social and Clinical Psychology, Faculty of Contemporary Culture, Hijiyama University, 4-1-1, Ushitashinmachi, Higashi-ku, Hiroshima, 732-8509, Japan
| | - Yasumasa Okamoto
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Shin-ichi Suzuki
- Faculty of Human Sciences, Waseda University 2-579-15, Mikajima, Tokorozawa, Saitama 359-1192, Japan
| | - Akiko Kinoshita
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Shinpei Yoshimura
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Atsuo Yoshino
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Yoshihiko Kunisato
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Shigeto Yamawaki
- Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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Abstract
Treatment-resistant depression (TRD) presents major challenges for both patients and clinicians. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health's (NIMH) STAR*D (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly. Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment. Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available. Pharmacological treatments of TRD can be grouped in two main categories: 'switching' or 'combining'. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favour of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission. The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. Several experimental pharmaceutical treatment alternatives for TRD are also being explored in combination with antidepressants or as monotherapy. These less studied alternative compounds include pindolol, inositol, CNS stimulants, hormones, herbal supplements, omega-3 fatty acids, S-adenosyl-L-methionine, folic acid, lamotrigine, modafinil, riluzole and topiramate. In summary, despite an increasing variety of choices for the treatment of TRD, this condition remains universally undefined and represents an area of unmet medical need. There are few known approved pharmacological agents for TRD (aripiprazole and OFC) and overall outcomes remain poor. This might be an indication that depression itself is a heterogeneous condition with a great diversity of pathologies, highlighting the need for careful evaluation of individuals with depressive symptoms who are unresponsive to treatment. Clearly, more research is needed to provide clinicians with better guidance in making those treatment decisions--especially in light of accumulating evidence that the longer patients are unsuccessfully treated, the worse their long-term prognosis tends to be.
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Affiliation(s)
- Richard C Shelton
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Abstract
The aim of the present study was to critically appraise current conceptual approaches; demographic, neurobiological and clinical correlates; and management strategies of treatment-resistant depression (TRD), especially in light of recent research findings. To this end, a review of the relevant English-language literature was undertaken using Medline, Embase and Psychinfo. TRD has been defined in conceptually restrictive terms as symptomatic non-response to physical therapies alone, with little systematic study of aetiology made. It is likely that a range of sociodemographic (such as higher socioeconomic status), genetic (such as variation in functional monoamine polymorphisms) and clinical variables (such as signal hyperintensities seen on structural neuroimaging scans) are responsible for non-response in individuals. There is insufficient evidence to suggest that TRD is associated with specific subtypes of depression, physical comorbidity, personality or chronicity. The large-scale Sequenced Treatment Alternatives to Relieve Depression (STAR*D) and other studies have suggested that a structured psychotherapy such as cognitive behaviour therapy may be as effective as medication in initial drug non-responders. Also conventional alternatives such as the use of older antidepressant classes, pharmacological augmentation or electroconvulsive therapy in established cases of TRD are not as effective as traditionally thought. There is insufficient preliminary evidence to make formal recommendations about the use of novel brain stimulation techniques in TRD. TRD should be re-defined as the failure to reach symptomatic and functional remission after adequate treatment with physical and psychological therapies. Treatment resistance may be more usefully conceived within the context of well-defined cohorts such as patients with specific subtypes of depression. Although neurobiological markers such as gene polymorphisms, which are potentially predictive of medication tolerance and efficacy, may be used in the future, it is likely that sociocultural variables such as beliefs about depression, and evidence-based treatments for it, will also determine treatment resistance.
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Affiliation(s)
- Chanaka Wijeratne
- School of Psychiatry, University of New South Wales, Kensington, New South Wales, Australia.
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Rasmussen-Torvik LJ, McAlpine DD. Genetic screening for SSRI drug response among those with major depression: great promise and unseen perils. Depress Anxiety 2007; 24:350-7. [PMID: 17096399 DOI: 10.1002/da.20251] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This article examines evidence for the potential benefit of genetic testing for SSRI response, as well as potential ethical and practical implications of the implementation of this test into standard psychiatric practice. We reviewed three areas of the literature: the burden of treatment-resistant and treatment-intolerant major depressive disorders, the evidence for the value of genetic testing to predict drug response, and the ethical and practical issues of genetic testing in usual care. Treatment resistance and treatment intolerance are common for persons treated with selective serotonin reuptake inhibitors (SSRIs) and are associated with both financial and quality-of-life costs. There is strong evidence from association studies that some polymorphisms are associated with SSRI response. However, no randomized trials have yet tested the efficacy of genetic tests to improve outcome in those with treatment resistance or treatment intolerance to SSRIs. Given the nonspecific nature of the test proposed, several ethical concerns are also involved with administering the genetic tests to patients. A randomized trial comparing response in those treated with standard psychiatric care and in those treated with psychiatric care tailored as a result of genetic test results should be completed before the implementation of these tests can be considered. Additionally, the ethical and practical questions concerning the tests must be addressed now, so that the potential impact of these tests on patient care can be well understood prior to adoption in standard practice.
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Affiliation(s)
- Laura J Rasmussen-Torvik
- Division of Epidemiology and Community Health and Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA.
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Abstract
BACKGROUND In the past decade, in clinical psychiatry several investigations suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders. The aim of this paper was to illustrate the practical implications of sequential treatment strategy for depression in primary care, with particular reference to the increasingly common problem of recurrent depression. METHODS The Authors tried to integrate the evidence which derives from meta-analyses and comprehensive general reviews with the insights which derive from controlled studies concerned with specific populations. CONCLUSIONS The sequential treatment of mood disorders is an intensive, two-stage approach, which derives from the awareness that one course of treatment with a specific tool (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the affective disturbances of patients, both in research and in clinical practice settings. The aim of the sequential approach is to add therapeutic ingredients as long as they are needed. In this sense, it introduces a conceptual shift in clinical practice.
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Affiliation(s)
- C Rafanelli
- Department of Psychology, University of Bologna, Bologna, Italy.
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Papadimitriou GN, Dikeos DG, Soldatos CR, Calabrese JR. Non-pharmacological treatments in the management of rapid cycling bipolar disorder. J Affect Disord 2007; 98:1-10. [PMID: 16963126 DOI: 10.1016/j.jad.2006.05.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2005] [Accepted: 05/15/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Rapid cycling (RC) bipolar disorder is often treatment-resistant to pharmacotherapy. Non-pharmacological methods, however, are reasonable considerations in treatment refractory cases of bipolar patients. Thus, such methods may be useful in the management of RC, especially when drugs are not shown to be effective. METHOD This review is based on studies of all major non-pharmacological methods which are used in the management of bipolar disorder, by focusing on data regarding patients with a RC pattern of the illness. RESULTS Regarding biological treatments, for electroconvulsive therapy and sleep deprivation, there exists some evidence that they might be efficacious in RC patients for acute treatment as well as for prophylaxis from recurrences. Light therapy has not been shown to be efficacious in RC, while no published data exist for transcranial magnetic stimulation and vagus nerve stimulation. The non-biological treatments include psychotherapeutic and psychosocial interventions; these have not been tried particularly on RC patients, but their use should be expected to contribute to the overall management of the RC pattern as it does to that of mood disorder in general. LIMITATIONS Many data on which this review is based are drawn from case reports or non-randomised trials. CONCLUSIONS Non-pharmacological methods, either biological or non-biological (psychotherapies and psychoeducation), may be applied in the management of RC patients. These methods might be used in combination with the administration of drug treatment, based on the clinical experience of the physician and the individual characteristics of the patient.
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Affiliation(s)
- George N Papadimitriou
- Department of Psychiatry, Athens University Medical School, Eginition Hospital, Vas. Sofias 74, 11528 Athens, Greece.
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Overholser JC. Panacea or Placebo: The Historical Quest for Medications to Treat Depression. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2006. [DOI: 10.1007/s10879-006-9023-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Azocar F, Branstrom RB. Use of Depression Education Materials to Improve Treatment Compliance of Primary Care Patients. J Behav Health Serv Res 2006; 33:347-53. [PMID: 16752111 DOI: 10.1007/s11414-006-9030-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In a collaborative effort between a managed behavioral health organization, a health maintenance organization, and a state employer, this pilot study tested the value of mailing a depression education flyer to primary care patients who were recently prescribed antidepressant medications and an informational letter to their physician. The intervention, designed to improve use of behavioral healthcare services and antidepressant medication adherence, had a moderate impact on consistency of antidepressant medication use and on use of psychotherapy in combination with antidepressant medications. Additionally, intervention patients on combination treatment were more likely to stay on antidepressant medications into the continuation phase of treatment.
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Affiliation(s)
- Francisca Azocar
- United Behavioral Health, Behavioral Health Sciences, 425 Market Street, 27th Floor, San Francisco, CA 94105, USA.
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20
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Otto MW, Smits JAJ, Reese HE. Combined Psychotherapy and Pharmacotherapy for Mood and Anxiety Disorders in Adults: Review and Analysis. ACTA ACUST UNITED AC 2005. [DOI: 10.1093/clipsy.bpi009] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Treatment-resistant depression (TRD) typically refers to inadequate response to at least one antidepressant trial of adequate doses and duration. TRD is a relatively common occurrence in clinical practice, with up to 50% to 60% of the patients not achieving adequate response following antidepressant treatment. A diagnostic re-evaluation is essential to the proper management of these patients. In particular, the potential role of several contributing factors, such as medical and psychiatric comorbidity, needs to be taken into account. An accurate and systematic assessment of TRD is a challenge to both clinicians and researchers, with the use of clinician-rated or self-rated instruments being perhaps quite helpful. It is apparent that there may be varying degrees of treatment resistance. Some staging methods to assess levels of treatment resistance in depression are being developed, but need to be tested empirically.
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Affiliation(s)
- Maurizio Fava
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Fava GA, Ruini C. Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy. J Behav Ther Exp Psychiatry 2003; 34:45-63. [PMID: 12763392 DOI: 10.1016/s0005-7916(03)00019-3] [Citation(s) in RCA: 220] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article describes the main characteristics and technical features of a novel psychotherapeutic strategy, well-being therapy. This paper outlines the background of its development, the structure of well-being therapy, its key concepts and technical aspects. Well-being therapy is based on Ryff's multidimensional model of psychological well-being, encompassing six dimensions: autonomy, personal growth, environmental mastery, purpose in life, positive relations and self-acceptance. The goal of this therapy is improving the patients' levels of psychological well-being according to these dimensions, using cognitive-behavioral techniques. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive-behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological or psychotherapeutic treatments and in body image disturbances. The clinical studies supporting its efficacy are illustrated.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, Bologna 40127, Italy.
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Otto MW, Reilly-Harrington N, Sachs GS. Psychoeducational and cognitive-behavioral strategies in the management of bipolar disorder. J Affect Disord 2003; 73:171-81. [PMID: 12507750 DOI: 10.1016/s0165-0327(01)00460-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Despite advances in the pharmacologic treatment of bipolar disorder, it is clear that additional strategies are needed to provide patients with longer-term mood stability. Recent years have witnessed the development of a number of psychosocial strategies for bipolar disorder that are design as adjuncts to ongoing pharmacotherapy. In this article we describe psychoeducational and cognitive-behavioral approaches to the management of bipolar disorder, with emphasis on broader treatment packages that can be offered by cognitive-behavior therapists working in specialty bipolar clinics, as well as specific strategies that can be integrated into standard pharmacotherapy for the disorder. A growing body of evidence documents the potential value of these interventions, and large-scale studies are underway, including the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), which will provide outcome on these interventions from the perspective of large, multicenter trials.
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Affiliation(s)
- Michael W Otto
- Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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26
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Abstract
Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.
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Affiliation(s)
- Alastair J Flint
- Department of Psychiatry, University of Toronto, Toronto, Canada.
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Abstract
Treatment-resistant depression (TRD) is an important clinical problem. This paper briefly reviews the definition of TRD and summarizes methodological issues that pertain to treatment research. Recent studies of venlafaxine treatment for TRD also are reviewed. It is concluded that venlafaxine at higher doses is a reasonably well-tolerated and an effective alternative for patients with TRD and typically should be used before tricyclic antidepressants or monoamine oxidase inhibitors. Further research is needed to confirm the prediction that switching a SSRI nonresponder to venlafaxine is a more effective strategy than switching to a second SSRI. The relative merits of switching from a SSRI to venlafaxine versus adding a norepinephrine reuptake inhibitor also warrant careful study.
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Affiliation(s)
- M E Thase
- University of Pittsburgh School of Medicine, Department of Psychiatry, Pennsylvania, USA.
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Deckersbach T, Gershuny BS, Otto MW. Cognitive-behavioral therapy for depression. Applications and outcome. Psychiatr Clin North Am 2000; 23:795-809, VII. [PMID: 11147248 DOI: 10.1016/s0193-953x(05)70198-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article discusses cognitive-behavioral therapy for depression, including evidence for its efficacy and how to choose between this therapy and antidepressants. The use of this therapy to prevent relapse also is presented.
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Affiliation(s)
- T Deckersbach
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Asioli F, Fioritti A. [Electroshock (ESK) and electroconvulsive therapy (ECT)]. EPIDEMIOLOGIA E PSICHIATRIA SOCIALE 2000; 9:99-102. [PMID: 10893843 DOI: 10.1017/s1121189x00008289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To discuss the ethical and legal basis of ECT use in Italy, one year after the regulation set up by the Minister of Health. METHOD Literature review and presentation of authors' personal opinions. RESULTS Despite being the oldest somatic therapy still practised in psychiatry, ECT effectiveness has been systematically evaluated only during the last 20 years, and its clinical indications have become progressively restricted. Yet there are wide variations between countries and within each individual country about the extension, the modalities and the indications for its use. ECT seems to be practised mainly in large scale public psychiatric hospitals and in private clinics, but its use in systems following a community approach is very limited. Wide variations exist also with reference to the severity of regulations imposed by governments or suggested by professional associations. The extent of education and auditing by university centres varies considerably, but is generally considered unsatisfactory. There are still some reports about possible political and repressive use of ECT in some countries, especially developing ones. CONCLUSIONS The authors consider that every national system of care should have a clear policy and clear regulations about ECT. The provisions set up by the Italian Minister of Health seem to be consistent with Italian health policies and psychiatric community care.
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Abstract
Clinical depression is a common disorder with serious implications that is often misdiagnosed or underestimated. More than 50% of suicides are associated with a major depressive disorder, and depression can adversely impact a variety of other medical conditions. Although > or = 70% of depressions can respond to appropriate medications, few patients actually receive adequate medical therapy. This article reviews the definition of adequate therapy for depression, discusses common comorbid conditions, and examines the issue of true treatment resistance. Practical strategies for treatment-resistant depression, including switching classes of antidepressant drugs, combination therapy, augmentation strategies, and somatic therapies, are incorporated into a treatment algorithm.
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Kolko DJ, Brent DA, Baugher M, Bridge J, Birmaher B. Cognitive and family therapies for adolescent depression: Treatment specificity, mediation, and moderation. J Consult Clin Psychol 2000. [DOI: 10.1037/0022-006x.68.4.603] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rafanelli C, Park SK, Fava GA. New psychotherapeutic approaches to residual symptoms and relapse prevention in unipolar depression. Clin Psychol Psychother 1999. [DOI: 10.1002/(sici)1099-0879(199907)6:3<194::aid-cpp202>3.0.co;2-l] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fava GA, Ottolini F, Ruini C. The role of cognitive behavioural therapy in the treatment of unipolar depression. Acta Psychiatr Scand 1999; 99:394-6. [PMID: 10353457 DOI: 10.1111/j.1600-0447.1999.tb07249.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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34
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Thase ME. When are psychotherapy and pharmacotherapy combinations the treatment of choice for major depressive disorder? Psychiatr Q 1999; 70:333-46. [PMID: 10587988 DOI: 10.1023/a:1022042316895] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Treating major depressive disorder with the combination of psychotherapy and pharmacotherapy is highly valued by both psychiatrists and their patients. However, results of most systematic research studies suggest that this approach may be overvalued: evidence of additive benefits (in relation to the respective component therapies, alone) is meager. In this paper it is argued that the advantage of combined treatment may be limited to treatment of patients with more complex depressive disorders, including characteristics such as comorbidity, chronicity, treatment resistance, episodicity, and severity. Said another way, milder acute depressions, especially initial or sporadic episodes, probably do not warrant the routine use of psychotherapy and pharmacotherapy. By focusing attention on the patient subgroups most likely to show a true additive response to combined treatment, it may be possible to obtain maximum benefits from dwindling resources.
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Affiliation(s)
- M E Thase
- University of Pittsburgh School of Medicine, PA, USA.
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Renaud J, Axelson D, Birmaher B. A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents. Drug Saf 1999; 20:59-75. [PMID: 9935277 DOI: 10.2165/00002018-199920010-00006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Child and adolescent major depressive disorders are common and recurrent disorders. The prevalence of major depressive disorders is estimated to be approximately 2% in children and 4 to 8% in adolescents. Major depressive disorders in children are frequently accompanied by other psychiatric disorders, poor psychosocial outcome and a high risk of suicide and substance abuse, indicating the need for effective treatment and prevention. The use of antidepressant medications as the first line of treatment for children and adolescents with mild to moderate major depressive disorders has been questioned. However, some subgroups of patients may benefit from initial treatment with antidepressants. These subgroups may include patients who are unwilling or unable to undergo psychotherapy, have not responded to at least 8 to 12 sessions of psychotherapy, have bipolar, atypical or severe depression or have recurrent depression. Currently, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the first medication choice because of their efficacy, benign adverse effect profile, ease of use and low risk of death following an overdose. Further research in continuation and maintenance treatments, treatment of comorbid conditions, subtypes of depression, e.g. bipolar, atypical, seasonal, and combinations of pharmacotherapy and psychotherapy are needed. In addition, studies of the pharmacokinetics, pharmacodynamics and long term adverse effects of antidepressant medications in children and adolescents are warranted.
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Affiliation(s)
- J Renaud
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Western Psychiatric Institute and Clinic, Pennsylvania 15213, USA
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36
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Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. AACAP. J Am Acad Child Adolesc Psychiatry 1998; 37:63S-83S. [PMID: 9785729 DOI: 10.1097/00004583-199810001-00005] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Child and adolescent major depressive disorder and dysthymic disorder are common, chronic, familial, and recurrent conditions that usually persist into adulthood. These disorders appear to be manifesting at an earlier age in successive cohorts and are usually accompanied by comorbid psychiatric disorders, increased risk for suicide, substance abuse, and behavior problems. In addition, depressed youth frequently have poor psychosocial, academic, and family functioning, which highlights the importance of early identification and prompt treatment. Both psychotherapy and pharmacotherapy have been found to be beneficial for the acute treatment of youth with depressive disorders. Opinions vary regarding which of these treatments should be offered first and whether they should be offered in combination. In general, the choice of initial therapy depends on clinical and psychosocial factors and therapist's expertise. Based on the current literature and clinical experience, psychotherapy may be the first treatment for most depressed youth. However, antidepressants must be considered for those patients with psychosis, bipolar depression, severe depressions, and those who do not respond to an adequate trial of psychotherapy. All patients need continuation therapy and some patients may require maintenance treatment. Further research is needed on the etiology of depression; the efficacy of different types of psychotherapy; the differential effects of psychotherapy, pharmacotherapy, and integrated therapies; the continuation and maintenance treatment phases; treatment for dysthymia, treatment-resistant depression, and other subtypes of major depressive disorder; and preventive strategies for high-risk children and adolescents.
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