Clinical features of depression in outpatients with and without co-occurring general medical conditions in STAR*D: confirmatory analysis

Changes in insomnia symptoms among compulsory education students in China after the "Double Reduction" policy: a two-wave longitudinal study

OBJECTIVE

In July 2021, the "Double Reduction" policy was introduced in China, aiming to alleviate the burden of excessive homework and off-campus tutoring for students in the compulsory education stage. The purpose of this study is to explore the changes in students' insomnia symptoms and related factors after the policy implementation. Meanwhile, sex differences were further examined.

METHODS

The baseline survey (T1) began in April 2021 (pre-policy), with a follow-up (T2) conducted in December 2021 (post-policy). A total of 28,398 students completed both T1 and T2 surveys and were included in this study. Insomnia symptoms were measured at both T1 and T2 using three questions from the Youth Self-Report Insomnia Scale. Demographics and anxiety and depressive symptoms were collected at T1, and policy-related indicators were assessed at T2.

RESULTS

The prevalence of insomnia symptoms showed a slight decrease after the "Double Reduction" policy (9.9% vs. 9.2%). After controlling for demographics and anxiety and depressive symptoms, reduced homework (OR: 0.75 [0.65-0.86]), more family time (OR: 0.50 [0.44-0.57]), and reduced academic pressure (OR: 0.77 [0.71-0.83]) post-policy were related to a lower risk of new-onset insomnia symptoms. Additionally, more family time (OR: 0.59 [0.49-0.72]) and reduced academic pressure (OR:0.70 [0.56-0.86]) were factors against persistent insomnia symptoms. There were no significant sex differences in the associations between policy-related indicators and insomnia symptoms.

CONCLUSIONS

The "Double Reduction" policy has somewhat improved the students' insomnia symptoms. Extending family time, and alleviating homework and academic burden are considered measures for maintaining sleep health in students.

The effect of depression on non-suicidal self-injury and psychological status in adolescents with unipolar and bipolar disorders

OBJECTIVE

To investigate the effects of depression on non-suicidal self-injury (NSSI) and related psychological conditions in adolescents with unipolar disorder (UD) and bipolar disorder (BD), and to provide a basis for accurate prevention and intervention of NSSI behaviors in adolescents.

METHODS

This cross-sectional study collected data from adolescents aged 12-18 years with depressive episodes who exhibited NSSI behaviors and attended the psychiatric outpatient clinic of Huangshi City Psychiatric Specialized Hospital from 2018 to 2023. Depressive episodes were clinically diagnosed by two psychiatrists according to the ICD-10.

RESULTS

In terms of NSSI behavioral patterns and severity, adolescents with UD displayed more frequent behaviour of intentionally burning themselves with cigarettes and had more instances of self-inflicted suicidal thoughts that were not carried out compared to those with BD, and the differences between the two groups were statistically significant (P < 0.05). For psychological status, Nurses' Global Assessment of Suicide Risk (NGASR) scores were significantly higher in adolescents with BD than in those with UD (P < 0.05). There was a significant negative correlation between anxiety scores and the frequency of NSSI in adolescents with BD (P < 0.05); that is, the more anxious the adolescents with BD, the lower the frequency of NSSI. The NGASR scores of adolescents with UD and BD were significantly and positively correlated with the frequency of NSSI occurrences (P < 0.05); higher NGASR scores of adolescents with UD and BD corresponded with higher frequencies of NSSI.

CONCLUSION

The differences in NSSI behaviors between adolescents with UD and those with BD were statistically significant in terms of self-injury method and severity. Adolescents with UD experienced more severe consequences related to NSSI behaviors. Regarding psychological conditions, adolescents with BD are at a higher risk of suicide. An inverse relationship was observed between anxiety severity and the frequency of NSSI in adolescents with BD; severe anxiety was associated with lower NSSI frequency. Additionally, higher suicide risk was associated with a higher frequency of NSSI in adolescent patients with either UD or BD. Therefore, different prevention and intervention measures are needed to address NSSI behaviors in adolescents with UD and BD.

The effect of single-component sleep restriction therapy on depressive symptoms: A systematic review and meta-analysis

Sleep restriction therapy is a behavioural component within cognitive behavioural therapy for insomnia and is an effective standalone treatment for insomnia, but its effect on depressive symptoms remains unclear. This review aimed to synthesise and evaluate the impact of single-component sleep restriction therapy on depressive symptoms relative to a control intervention. We searched electronic databases and sleep-related journals for randomised controlled trials and uncontrolled clinical trials, published from 1 January 1986 until 19 August 2023, that delivered sleep restriction therapy to adults with insomnia. Random-effects meta-analysis of standardised mean differences and Cochrane risk of bias assessment were performed on randomised controlled trials, while uncontrolled clinical trials were discussed narratively. The meta-analysis was pre-registered on PROSPERO (ID: CRD42020191803). We identified seven randomised controlled trials (N = 1102) and two uncontrolled clinical trials (N = 22). Findings suggest that sleep restriction therapy is associated with a medium effect for improvement in depressive symptoms at post-treatment (Nc = 6, g = -0.45 [95% confidence interval = -0.70 to -0.21], p < 0.001) and a small effect at follow-up (Nc = 4, g = -0.31 [95% confidence interval = -0.45 to -0.16], p < 0.001). Five of the seven included randomised controlled trials were judged to have a high risk of bias. Standalone sleep restriction therapy appears to be efficacious for improving depressive symptoms at post-treatment and follow-up. However, conclusions are tentative due to the small number of trials and because none of the trials was performed in a population with clinically defined depression. Large-scale trials are needed to test the effect of sleep restriction therapy in patients experiencing depression and insomnia. Findings also highlight the need to improve the standardisation and reporting of sleep restriction therapy procedures, and to design studies with more rigorous control arms to reduce potential bias.

Effects of anhedonia on health-related quality of life and functional outcomes in major depressive disorder: A systematic review and meta-analysis

BACKGROUND

Major depressive disorder (MDD) is a heterogeneous group of mood disorders. A prominent symptom domain is anhedonia narrowly defined as a loss of interest and ability to experience pleasure. Anhedonia is associated with depressive symptom severity, MDD prognosis, and suicidality. We perform a systematic review and meta-analysis of extant literature investigating the effects of anhedonia on health-related quality of life (HRQoL) and functional outcomes in persons with MDD.

METHODS

A literature search was conducted on PubMed, OVID databases, and SCOPUS for published articles from inception to November 2023, reporting on anhedonia and patient-reported outcomes in persons with MDD. The reported correlation coefficients between anhedonia and self-reported measures of both HRQoL and functional outcomes were pooled using a random effects model.

RESULTS

We identified 20 studies that investigated anhedonia with HRQoL and/or functional outcomes in MDD. Anhedonia as measured by the Snaith-Hamilton Pleasure Scale (SHAPS) scores had a statistically significant correlation with patient-reported HRQoL (r = -0.41 [95 % CI = -0.60, -0.18]) and functional impairment (r = 0.39 [95 % CI = 0.22, 0.54]).

LIMITATIONS

These preliminary results primarily investigate correlations with consummatory anhedonia and do not distinguish differences in anticipatory anhedonia, reward valuation or reward learning; therefore, these results require replication.

CONCLUSIONS

Persons with MDD experiencing symptoms of anhedonia are more likely to have worse prognosis including physical, psychological, and social functioning deficits. Anhedonia serves as an important predictor and target for future therapeutic and preventative tools in persons with MDD.

[Overview of chronobiological and sleep medical aspects of depression in adolescents]

Changes in sleep are reported in adolescents with depression with a frequency of up to 71%. Aspects of chronobiology and sleep based on the current scientific literature are illustrated and summarized in this narrative review. The circadian clock synchronizes organisms to the light-dark structure of the environment. The individual synchronization is called "chronotype." Chronotype changes according to age, among other factors, and adolescents experience the latest chronotypes overall. The potential discrepancy between internal and external time is called "social jetlag." Social jetlag is especially pronounced during adolescence. It is associated with numerous health risks, such as depression. Changes in sleep behavior in affective disorders and its comorbidity to depression have also been well described in the literature. In this article, underlying concepts from chronobiology and sleep medicine are initially summarized. Then, health risks of disrupted sleep-wake behavior are described, and connections to depression specifically during adolescence are drawn. The article concludes with clinical recommendations for sleep disorders and depression during adolescence as well as suggestions for further research.

Interaction effects between insomnia and depression on risk of out-of-hospital cardiac arrest: Multi-center study

BACKGROUND

Insomnia and depression have been known to be risk factors of several diseases, including coronary heart disease. We hypothesized that insomnia affects the out-of-hospital cardiac arrest (OHCA) incidence, and these effects may vary depending on whether it is accompanied by depression. This study aimed to determine the association between insomnia and OHCA incidence and whether the effect of insomnia is influenced by depression.

METHODS

This prospective multicenter case-control study was performed using Phase II Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiology Surveillance (CAPTURES-II) project database for OHCA cases and community-based controls in Korea. The main exposure was history of insomnia. We conducted conditional logistic regression analysis to estimate the effect of insomnia on the risk of OHCA incidence and performed interaction analysis between insomnia and depression. Finally, subgroup analysis was conducted in the patients with insomnia.

RESULTS

Insomnia was not associated with increased OHCA risk (0.95 [0.64-1.40]). In the interaction analysis, insomnia interacted with depression on OHCA incidence in the young population. Insomnia was associated with significantly higher odds of OHCA incidence (3.65 [1.29-10.33]) in patients with depression than in those without depression (0.84 [0.59-1.17]). In the subgroup analysis, depression increased OHCA incidence only in patients who were not taking insomnia medication (3.66 [1.15-11.66]).

CONCLUSION

Insomnia with depression is a risk factor for OHCA in the young population. This trend was maintained only in the population not consuming insomnia medication. Early and active medical intervention for patients with insomnia may contribute to lowering the risk of OHCA.

Slow Wave Sleep Deficits in the Flinders Sensitive Line Rodent Model of Depression: Effects of Medial Forebrain Bundle Deep-Brain Stimulation

Major Depressive Disorder (MDD) is an affective disorder typically accompanied by sleep disturbances. Deep brain stimulation (DBS) of the medial forebrain bundle (MFB) is an emerging intervention for treatment-resistant depression, but its effect on sleep has not been closely examined. Here we aimed to characterise sleep deficits in the Flinders sensitive line, an established rodent model of depression, and investigate the consequences of MFB stimulation on sleep-related phenotypes. Rats were implanted with bilateral stimulation electrodes in the MFB, surface electrodes to record electrocorticography and electromyography for sleep scoring and electrodes within the prelimbic cortex, nucleus accumbens (NAc) and dorsal hippocampus. Recordings of sleep and oscillatory activity were conducted prior to and following twenty-four hours of MFB stimulation. Behavioural anti-depressant effects were monitored using the forced swim test. Previously unreported abnormalities in the Flinders sensitive line rats were observed during slow wave sleep, including decreased circadian amplitude of its rhythm, a reduction in slow wave activity and elevated gamma band oscillations. Previously established rapid eye movement sleep deficits were replicated. MFB stimulation had anti-depressant effects on behavioural phenotype, but did not significantly impact sleep architecture; it suppressed elevated gamma activity during slow wave sleep in the electrocorticogram and prelimbic cortex signals. Diverse abnormalities in Flinders sensitive line rats emphasise slow wave sleep as a state of dysfunction in affective disorders. MFB stimulation is able to affect behaviour and sleep physiology without influencing sleep architecture. Gamma modulation may represent a component of antidepressant mechanism.

Incremental health care resource use and costs among adult patients with depression and treated for insomnia with zolpidem, trazodone, or benzodiazepines

OBJECTIVE

To quantify health care resource utilization (HCRU) and costs associated with insomnia treated with commonly prescribed insomnia medications among patients with depression.

METHODS

A retrospective cohort study was conducted using IBM MarketScan Commercial and Medicare Supplemental Databases to identify adults with: (1) ≥1 ICD-9/ICD-10 code for depression; (2) ≥1 commonly prescribed medication for insomnia (zolpidem immediate release [IR], zolpidem extended release [ER], trazodone, or benzodiazepines); and (3) ≥12 months of eligibility before and after initiating insomnia medication. A 1:1 age- and sex-matched control cohort with depression but without sleep-related disorders was identified. Adjusted HCRU and costs were compared using generalized linear models.

RESULTS

A total of 21,027 patients (mean age = 48.3 years, 69.5% female) with depression and treated insomnia (D + TI; 1.9% zolpidem ER, 32.0% zolpidem IR, 50.0% trazodone, 16.1% benzodiazepines) were matched to controls. Although mean number of inpatient visits were similar (0.1 for both), relative to controls, D + TI had a higher mean number of ED (0.2 vs 0.1, p < .001) and outpatient visits (2.2 vs 1.3, p < .001). Adjusted total costs per patient per month were higher among D + TI patients ($2450 vs $1095, p < .001). Inpatient and ED costs were higher among patients prescribed zolpidem IR, trazodone, or benzodiazepines, but not zolpidem ER.

CONCLUSIONS

Relative to controls with depression but without sleep disorders, overall, health care costs for adults with D + TI were 2.2-fold higher; costs and HCRU varied by insomnia medication. Further study of the impact of newer insomnia treatments on patient outcomes in depression and comorbid insomnia is warranted.

A Microbiome-Driven Approach to Combating Depression During the COVID-19 Pandemic

The significant stressors brought about and exacerbated by COVID-19 are associated with startling surges in mental health illnesses, specifically those related to depressive disorders. Given the huge impact of depression on society, and an incomplete understanding of impactful therapeutics, we have examined the current literature surrounding the microbiome and gut-brain axis to advance a potential complementary approach to address depression and depressive disorders that have increased during the COVID-19 pandemic. While we understand that the impact of the human gut microbiome on emotional health is a newly emerging field and more research needs to be conducted, the current evidence is extremely promising and suggests at least part of the answer to understanding depression in more depth may lie within the microbiome. As a result of these findings, we propose that a microbiome-based holistic approach, which involves carefully annotating the microbiome and potential modification through diet, probiotics, and lifestyle changes, may address depression. This paper's primary purpose is to shed light on the link between the gut microbiome and depression, including the gut-brain axis and propose a holistic approach to microbiome modification, with the ultimate goal of assisting individuals to manage their battle with depression through diet, probiotics, and lifestyle changes, in addition to offering a semblance of hope during these challenging times.

Clinical and demographic predictors of response to anodal tDCS treatment in major depression disorder (MDD)

Transcranial direct current stimulation (tDCS) of the prefrontal cortex is known as a promising intervention in major depression disorder (MDD). However, limited information on predictors of therapeutic response to tDCS are available. This study aimed to investigate clinical and demographic predictors of therapeutic response in patients taking no medications. For this purpose, the required data were collected from 2 independent tDCS trials on 116 MDD patients. Accordingly, 84 patients underwent 10 sessions of 2 mA tDCS daily each one lasted for 20 min and 32 patients received 10 twice sessions of 2 mA tDCS daily each one lasted for 20 min. Anodal electrode was located over the left dorsolateral prefrontal cortex (DLPFC), and cathode was over the right supraorbital region. Depression symptoms and the underlying clinical dimensions were assessed using the Beck Depression Inventory (BDI-II) at baseline and after the tDCS treatment. Of the included 116 patients, 47.4% showed an antidepressant response. Results of logistic regression analysis showed that the reduction in BDI-II scores after tDCS was associated with the baseline values of cognitive-affective symptoms factor, loss of pleasure, loss of interest, and sleep problems. Pronounced sleep disturbances and cognitive-affective symptoms were identified as the potential clinical predictors of response to tDCS. However, more prospective tDCS studies are necessary to validate the predictive value of the derived model.

[Multimorbidity and use of health services by individuals with restrictions on habitual activities: the Pró-Saúde Study]

The study aimed to assess the use of health services and the association with different measures of multimorbidity. This was a cross-sectional study nested in the Pró-Saúde Study, a longitudinal study of municipal technical and administrative employees in Rio de Janeiro, Brazil. Data were analyzed from phase 2 (2001-2002), and the study population consisted of 733 individuals who reported restrictions on habitual activities due to health problems in the 15 days prior to the data collection. The search for a health service (outcome variable) was used as the proxy for use of health services. Multimorbidity was assessed by simple count and the Cumulative Illness Rating Scale, generating four exposure variables: number of self-reported diseases, multimorbidity (2 or more diseases), and total score and number of systems affected. The analyses stratified by sex used Poisson regression models with robust variance, adjusted by age and schooling. Women showed higher mean values than men for all the measures, with 51% classified as having multimorbidity. In men, multimorbidity increased by 43% (95%CI: 1.11-1.84) the probability of using health services, while there was no statistically significant association in women. For men, each additional disease increased the probability of use of a health service by 14% (95%CI: 1.05-1.24). There were evident differences in the use of health services and multimorbidity according to sex. Explaining these patterns becomes relevant for the provision of efficient, coordinated, and safe care for persons with multimorbidity.

Triple comorbid trajectories of alcohol, cigarette, and marijuana use from adolescence to adulthood predict insomnia in adulthood

Approximately 9% of adults report the symptoms of insomnia, and there are a number of adverse consequences of insomnia. This could be a public health concern. The current study seeks plausible longitudinal predictors of insomnia for prevention purposes. A community sample of 674 participants (53% African Americans and 47% Puerto Ricans; 60% were females) were recruited from the Harlem Longitudinal Development Study. We applied a growth mixture model to obtain the triple trajectories of alcohol, cigarette, and marijuana use. Logistic regression analyses were then conducted to examine the associations between the triple trajectory groups from mean age 14 to 36 and insomnia at age 36. The estimated prevalence of insomnia is 7.1%. A five-group triple trajectory model was selected: A) Increasing use of all three substances (18%); B) Moderate use of alcohol and marijuana, and high use of cigarette (11%); C) Moderate use of alcohol and cigarette, and experimental use of marijuana (3%); D) Moderate use of all three substances (5%); and E) No or low use of all three substances (63%). Among the five trajectory groups, the increasing use of all three substances group (AOR = 2.71, p-value = .011) was associated with an increased likelihood of having insomnia as compared to the no or low use of all three substances group. Treatment programs to quit or reduce the use of alcohol, cigarette, and marijuana may help decrease the prevalence of insomnia. This could lead to improvements in individualized treatments for patients who have symptoms of insomnia and who also use substances.

The effect of chronic physical illnesses on psychiatric hospital admission in patients with recurrent major depression

People with major depressive disorder (MDD) have an increased burden of chronic physical illnesses (CPI). However, information about the effect of CPIs on recurrent MDD treatment outcome is limited. The objective of this study was to explore whether the number of CPIs in patients with recurrent MDD was associated with higher rate of psychiatric admissions. Data were collected for a consecutive sample of 190 patients diagnosed with recurrent MDD. The key outcome was the number of psychiatric admissions following psychiatric diagnosis. The independent variable was the number of CPIs. The effects of different clinical, sociodemographic, and lifestyle confounding factors were controlled using robust regression. The patients with CPI had significantly more psychiatric admissions than the patients without CPI, and the number of CPIs was significantly associated with the number of psychiatric admissions. The results of our study largely confirmed that more than two CPIs in patients diagnosed with recurrent MDD are associated with higher rates of psychiatric admission, independent of psychiatric comorbidities and other clinical and sociodemographic factors. These findings indicate that to improve treatment outcome and to reduce recurrence, it is crucial to enhance early recognition and treatment of physical comorbidity.

Sleep quality and psychosocial characteristics of patients with painful post-traumatic trigeminal neuropathies

OBJECTIVES

The aim of this study was to explore how pain and psychological distress influence the sleep quality of patients with painful post-traumatic trigeminal neuropathy (PPTN).

STUDY DESIGN

Thirty-two patients with a diagnosis of PPTN according to the International Classification for Headache Disorders of the International Headache Society were enrolled. All patients completed a number of questionnaires that examined sleep quality, psychological distress, and quality of life.

RESULTS

The global Pittsburg Sleep Quality Index (PSQI) score was "5" or greater in 75% of the patients. Additionally, the Symptom Check List-90-Revised (SCL-90-R) global severity index (GSI) revealed that 71.9% of the study sample reported values of psychological distress over the level of clinical significance. Sleep quality was analyzed through a linear regression model of global PSQI (dependent variable) that included gender, age, pain intensity, and pain duration (independent variables). This model revealed a significant positive association between the PSQI global score and the SCL-90-R GSI that was independent of age, gender, pain intensity, and duration.

CONCLUSIONS

Patients with PPTN present higher levels of sleep disturbance and psychological distress compared with the general population. Sleep quality disturbances and levels of psychological distress are strongly associated and seem to be independent of age, gender, medication use, pain intensity and duration.

Depressive Symptoms and Sleep Efficiency Sequentially Mediate Racial Differences in Temporal Summation of Mechanical Pain

BACKGROUND

Racial differences in endogenous pain facilitatory processes have been previously reported. Evidence suggests that psychological and behavioral factors, including depressive symptoms and sleep, can alter endogenous pain facilitatory processes. Whether depressive symptoms and sleep might help explain racial differences in endogenous pain facilitatory processes has yet to be determined.

PURPOSE

This observational, microlongitudinal study examined whether depressive symptoms and sleep were sequential mediators of racial differences in endogenous pain facilitatory processes.

METHODS

A total of 50 (26 African American and 24 non-Hispanic white) community-dwelling adults without chronic pain (mean 49.04 years; range 21-77) completed the Center for Epidemiological Studies Depression Scale prior to seven consecutive nights of sleep monitoring with actigraphy in the home environment. Participants subsequently returned to the laboratory for assessment of endogenous pain facilitation using a mechanical temporal summation protocol.

RESULTS

Findings revealed greater depressive symptoms, poorer sleep efficiency, and greater temporal summation of mechanical pain in African Americans compared to non-Hispanic whites. In a sequential mediation model, greater depressive symptoms predicted poorer sleep efficiency (t = -2.55, p = .014), and poorer sleep efficiency predicted enhanced temporal summation of mechanical pain (t = -4.11, p < .001), particularly for African Americans.

CONCLUSIONS

This study underscores the importance of examining the contribution of psychological and behavioral factors when addressing racial differences in pain processing. Additionally, it lends support for the deleterious impact of depressive symptoms on sleep efficiency, suggesting that both sequentially mediate racial differences in endogenous pain facilitation.

Major Depression Comorbid with Medical Conditions: Analysis of Quality of Life, Functioning, and Depressive Symptom Severity

Background

The presence of Major Depressive Disorder (MDD) is often comorbid in patients with a variety of general medical conditions (GMCs) which could lead to less favorable outcomes.

Objective

The goal of this analysis is to examine functional outcomes of QOL and functioning before and after antidepressant treatment among patients with MDD with and without GMCs.

Methods

We performed a secondary analysis based on the STAR*D database. The analysis included two patient groups from the STAR*D trial: 1,198 patients comorbid with MDD and GMCs (MDD + GMC) and 1,082 patients with MDD and no GMCs (MDDnoGMC), as defined by the Cumulative Illness Rating Scale. We analyzed depressive symptom severity, functioning and quality of life (QOL) before and after level 1 treatment with citalopram.

Results

At baseline, the MDD + GMC group had significantly lower QOL (p < 0.001) and functioning (p = 0.001) than the MDDnoGMC group, although depressive symptom severity was not significantly different. Following antidepressant treatment, QOL, functioning and depressive symptom severity significantly improved for both MDD + GMC and MDDnoGMC groups. However, patients with MDD + GMC were more likely to experience severe impairments in QOL in (56.8% vs. 43.5% for MDDnoGMC, p < 0.001) and functioning (42.5% vs. 29.3% for MDDnoGMC, p < 0.001) following treatment. The remission rate was significantly lower for MDD + GMC (30.6% vs. 41.1% for MDDnoGMC, p < 0.001).

Conclusions

Our findings suggest that antidepressant treatment had a positive impact on patients with and without GMCs. However, those with GMCs experienced not only a lower remission rate, but also continued to experience more significantly severe impairments in QOL and functioning.

Applications of Yoga in Psychiatry: What We Know

Yoga has been in use for thousands of years in the East as a healing modality. Western practitioners are now starting to recognize the potential of yoga-based treatments. The purpose of this article is to explore the evidence-base of yoga-based treatments for depression and anxiety with the purpose of furthering the integration of yoga into conventional Western mental health treatment plans.

German general practitioners' self-reported management of patients with chronic depression

BACKGROUND

Patients with chronic depression (persisting symptoms for ≥2 years) are a clinically relevant group with extensive (co)morbidity, high functional impairment and associated costs in primary care. The General Practitioner (GP) is the main health professional attending to these patients. The aim of this study was to examine the GPs' perception on managing patients with chronic depression.

METHODS

We performed an explorative cross-sectional study with a systematic sample of GPs in central Germany. Source of data was a written questionnaire (46 items). Descriptive analysis was carried out.

RESULTS

Two hundred twenty (out of 1000; 22%) GPs participated. 93% of the GPs distinguish between care for patients with chronic depression and acute depressive episode. 92% would recommend psychotherapeutic co-treatment to the chronically depressed patient. 52% of GPs would favour a general restraint on antidepressants (ADs) in older chronically depressed patients (≥ 75 years) whereas 40% suggest long-term pharmacotherapy. If severe physical comorbidity is present GPs would be restrictive in prescribing ADs (65%) or would urgently refer to specialist psychiatric services (40%). In case of a comorbid anxiety disorder 66% of the GPs would suggest a combined psycho- und pharmacotherapy. If a substance use disorder coexists 84% would prefer urgent referrals to specialist services.

CONCLUSIONS

Participating GPs report awareness towards chronic depression in their patients. Physical and mental comorbidity seem to play an important role in GPs' treatment decisions.

Randomized single-blind multicenter trial comparing the effects of standard and augmented acupuncture protocols on sleep quality and depressive symptoms in patients with depression

The study was aimed to compare the effects of standard and augmented acupuncture on depressive symptoms and sleep disturbances in patients with depression. This is a randomized, single-blind, multicenter trial. 140 subjects with clinical insomnia (score of ≥ 7 on the Pittsburgh Sleep Quality Index (PSQI)) were randomized to the standard (LI4, LIV3, EX-HN3, and GV20) or augmented (LI4, LIV3, EX-HN3, GV20, LU7, and KID6, including intradermal needles for sustained treatment) acupuncture groups. Participants received two sessions weekly for six weeks. In trial, The primary outcomes were improvements in PSQI and the Hamilton Rating Scale (HAMD). Secondary outcomes were treatment credibility and adverse events. Outcomes were assessed at baseline, week 3, end of treatment, and 4-week follow-up. From the 105 randomized patients, 89 completed the trial and were included in the final analyses. Better efficacy was observed in the augmented group compared with the standard acupuncture to improve the PSQI and HAMD at week 3, end of treatment, and 4-week follow-up (all p < .05). The HAMD scores improved with time, except between end of treatment and 4-week follow-up, while in the standard group, HAMD scored improved from baseline to week 3, and stopped improving thereafter. The PSQI scores improved with time in the two groups, except between end of treatment and 4-week follow-up. Compared with the standard protocol, the augmented acupuncture protocol had a better efficacy to treat depression and to improve sleep quality of patients with depression.

Major Depressive Disorder in Patients With Doctoral Degrees: Patient-reported Depressive Symptom Severity, Functioning, and Quality of Life Before and After Initial Treatment in the STAR*D Study

OBJECTIVE

This study examined patients with medical or doctoral degrees diagnosed with major depressive disorder (MDD) by analyzing patient-reported depressive symptom severity, functioning, and quality of life (QOL) before and after treatment of MDD.

METHODS

Analyses were conducted in a sample of 2280 adult outpatient participants with MDD from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study with complete entry and exit scores for the level 1 (citalopram monotherapy) trial. The sample contained 62 participants who had completed medical or doctoral degrees (DOCS) and 2218 participants without medical or doctoral degrees (non-DOCS). QOL was assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire, functioning was assessed with the Work and Social Adjustment Scale, and depressive symptom severity was assessed with the Quick Inventory of Depressive Symptomatology-Self Report.

RESULTS

Both groups (DOCS and non-DOCS) had significant improvement in depressive symptom severity, functioning, and QOL following treatment (with equivalent improvements in mean change values). However, the DOCS group demonstrated larger effect sizes in symptom reduction for depression, increase in functioning, and improvement in QOL compared with the non-DOCS group. Participants who achieved remission from MDD at exit showed significantly greater improvement than nonremitters on functioning and QOL.

CONCLUSIONS

Findings from this study indicated that, following citalopram monotherapy, the participants in the DOCS group achieved greater reductions in depressive symptom severity (based on effect sizes) than the participants in the non-DOCS group. For both treatment groups, the findings also showed the positive effect that remission status from MDD can have on QOL and functioning.

It is a painful somatic symptom, not the history of cancer/malignancy that is associated with depression: findings from multiple national surveys

Medical case management has improved in the past few decades, changing the dynamic interaction between depression and prevalent medical diseases. It is relevant to describe the comorbidity between depression and medical diseases to further improve the effectiveness of case management. We analyzed the data of adults aged 20 years and older, who completed depression screening as a part of the National Health and Nutrition Examination Survey, 2005 to 2012. Depression was ascertained using the Patient Health Questionnaire, a 9-item screening instrument asking about the frequency of depression symptoms over the past 2 weeks. Comorbid diseases were assessed in a self-reported personal interview on doctor-diagnosed health conditions. The associations between depression and medical diseases were limited to the diseases with painful somatic symptoms. Reported from 19.78% of men and 27.84% of women, arthritis was the most prevalent chronic disease, and was the only one consistently associated with depression. The odds ratio of moderate to severe depression was 1.65 (95% confidence interval = 1.12-2.44) for men and 2.11 (1.63-2.99) for women with arthritis compared with their counterparts free of arthritis. Moderate/severe depression was associated with a history of heart disease among men (2.45 [1.19-5.06]) and angina/angina pectoris among women (2.13 [1.07-4.26]). No associations were found between depression and cancer/malignancy, either among men or women. The potential impact of pain management on depression prevention among general population is substantial; more efforts are needed to assess chronic pain to facilitate timely prevention and treatment of depression and comorbid medical conditions.

Trajectories of Cigarette Smoking Beginning in Adolescence Predict Insomnia in the Mid Thirties

BACKGROUND

Insomnia is increasingly recognized as a public health concern in modern society. Insomnia diagnoses appear to be increasing and are associated with poor health outcomes. They may cost $100 billion annually in health services.

OBJECTIVE

Given the adverse consequences of insomnia such as cardiovascular disease, diabetes, and depression, the present study was designed to examine the relationship of the trajectories of earlier cigarette smoking and later insomnia. The ultimate goal is to reduce the prevalence of insomnia.

METHODS

674 participants (53% African Americans, 47% Puerto Ricans, 60% females) were surveyed at 6 points in time. We employed the growth mixture model to obtain the trajectories of cigarette smoking from age 14 to 32. We used logistic regression analyses to examine the associations between the trajectories of smoking and insomnia.

RESULTS

Males were less likely to have insomnia than females (Adjusted odds ratio: AOR = 0.34, p < .05). A higher Bayesian posterior probability (BPP) for the chronic smoking trajectory group (AOR = 2.69, p < .05) and for the moderate smoking trajectory group (AOR = 5.33, p < .01) was associated with an increased likelihood of having insomnia at age 36 compared with the BPP of the no or low smoking trajectory group.

CONCLUSIONS

Prevention and treatment programs for individuals who suffer from insomnia should be implemented in parallel with programs for smoking cessation. From a public health perspective, our longitudinal study that examined the association between earlier smoking trajectories and later insomnia suggests that treatments designed to reduce or cease smoking may lessen the occurrence of symptoms of insomnia.

Quality of life in major depressive disorder before/after multiple steps of treatment and one-year follow-up

OBJECTIVE

This study examines the impact of major depressive disorder (MDD) and its treatment on quality of life (QOL).

METHOD

From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, we analyzed complete data of 2280 adult MDD out-patients at entry/exit of each level of antidepressant treatments and after 12 months of entry to follow-up. QOL was measured using the QOL Enjoyment and Satisfaction Questionnaire (Q-LES-Q). The proportions of patients scoring 'within-normal' QOL (within 10% of Q-LES-Q community norms) and those with 'severely impaired' QOL (>2 SD below Q-LES-Q community norms) were analyzed.

RESULTS

Before treatment, no more than 3% of MDD patients experienced 'within-normal' QOL. Following treatment, statistically significant improvements were detected; however, the proportion of patients achieving 'within-normal' QOL did not exceed 30%, with >50% of patients experiencing 'severely impaired' QOL. Although remitted patients had greater improvements compared with non-remitters, 32-60% continued to experience reduced QOL. 12-month follow-up data revealed that the proportion of patients experiencing 'within-normal' QOL show a statistically significant decrease in non-remitters.

CONCLUSION

Symptom-focused treatments of MDD may leave a misleading impression that patients have recovered when, in fact, they may be experiencing ongoing QOL deficits. These findings point to the need for investigating specific interventions to ameliorate QOL in MDD.

General medical burden in bipolar disorder: findings from the LiTMUS comparative effectiveness trial

OBJECTIVE

This study examined general medical illnesses and their association with clinical features of bipolar disorder.

METHOD

Data were cross-sectional and derived from the Lithium Treatment - Moderate Dose Use Study (LiTMUS), which randomized symptomatic adults (n = 264 with available medical comorbidity scores) with bipolar disorder to moderate doses of lithium plus optimized treatment (OPT) or to OPT alone. Clinically significant high and low medical comorbidity burden were defined as a Cumulative Illness Rating Scale (CIRS) score ≥4 and <4 respectively.

RESULTS

The baseline prevalence of significant medical comorbidity was 53% (n = 139). Patients with high medical burden were more likely to present in a major depressive episode (P = .04), meet criteria for obsessive-compulsive disorder (P = .02), and experience a greater number of lifetime mood episodes (P = 0.02). They were also more likely to be prescribed a greater number of psychotropic medications (P = .002). Sixty-nine per cent of the sample was overweight or obese as defined by body mass index (BMI), with African Americans representing the racial group with the highest proportion of stage II obesity (BMI ≥35; 31%, n = 14).

CONCLUSION

The burden of comorbid medical illnesses was high in this generalizable sample of treatment-seeking patients and appears associated with worsened course of illness and psychotropic medication patterns.

Prevalence and clinical characteristics of the DSM IV major depression among general internal medicine patients

OBJECTIVE

The aim of this study was to investigate the prevalence and clinical characteristics of the DSM IV major depressive disorder (MDD) among patients admitted to the General Internal Medicine Service of the Geneva University Hospital.

METHOD

557 patients admitted to the IM of the Geneva University Hospital aged 18 to 70 were investigated. Each subject was assessed by a clinical psychologist using the SCID (Structured Clinical Interview Depression for DSM-IV) questionnaire.

RESULTS

69 patients (12.4%) met diagnostic criteria for MDD (men: 8.8%, women: 16.9%, p=.004). Among subjects with major depression, depressed mood (97%), fatigue (91%), and diminished interest and pleasure (81%) were the most prevalent symptoms. Recurrent thoughts of death were present in 48% of depressed patients.

CONCLUSIONS

This study raises further evidence that an elevated proportion of patients admitted to an acute care general internal medicine facility meet DSM IV criteria for MDD with nearly half of depressed patients suffering from recurrent thoughts of death. It emphasizes the necessity of a targeted, continuous, and active support given by the psychiatry liaison service in the internal medicine setting.

Screening for sleep dysfunction after traumatic brain injury

Numerous studies on the high prevalence of sleep disorders in individuals with traumatic brain injury (TBI) have been conducted in the past few decades. These disorders can accentuate other consequences of TBI, negatively impacting mood, exacerbating pain, heightening irritability, and diminishing cognitive abilities and the potential for recovery. Nevertheless, sleep is not routinely assessed in this population. In our review, we examined the selective screening criteria and the scientific evidence regarding screening for post-TBI sleep disorders to identify gaps in our knowledge that are in need of resolution. We retrieved papers written in the English-language literature before June 2012 pertinent to the discussion on sleep after TBI found through a PubMed search. Within our research, we found that sleep dysfunction is highly burdensome after TBI, treatment interventions for some sleep disorders result in favorable outcomes, sensitive and specific tests to detect sleep disorders are available, and the cost-effectiveness and sustainability of screening have been determined from other populations. The evidence we reviewed supports screening for post-TBI sleep dysfunction. This approach could improve the outcomes and reduce the risks for post-TBI adverse health and nonhealth effects (e.g., secondary injuries). A joint sleep and brain injury collaboration focusing on outcomes is needed to improve our knowledge.

Can sleep disturbance in depression predict repetitive transcranial magnetic stimulation (rTMS) treatment response?

Treatment for depression is not effective in all patients and it is therefore important to identify factors that can be used to tailor treatments. One potential factor is insomnia. Several repetitive transcranial magnetic stimulation (rTMS) studies have reported on this symptom, however, they did not take into account the presence of hypersomnia or that insomnia was related to their outcome measure. Our aim was to investigate whether baseline sleep disruption was related to rTMS treatment response. We pooled data from four clinical trials using rTMS to treat depression, including 139 subjects in data analysis. Insomnia was measured using the Hamilton Depression Rating Scale (HamD) sleep questions and hypersomnia from the Beck Depression Inventory (BDI). To reduce the possible impact of insomnia on our treatment response outcome we created an adjusted HamD score which omitted sleep items. Sleep disturbances were common in our study: 66% had insomnia and 38% hypersomnia. Using regression analysis with our adjusted HamD score we found no relation between baseline insomnia or hypersomnia and rTMS treatment response. Our data are consistent with previous studies; however, this is the first rTMS study to our knowledge that has attempted to dissociate baseline insomnia from the HamD outcome measure and to report no relationship between hypersomnia and rTMS outcome.

Treatment of depression in individuals living with HIV/AIDS

BACKGROUND

Depression is common in patients with HIV/AIDS, and can have an impact on quality of life, as well as various health outcomes. This study was designed to observe the efficacy of standard treatment of depression in human immunodeficiency virus (HIV) (+) individuals in an urban psychiatric clinic.

METHODS

This study consisted of a retrospective chart review of patients presenting for psychiatric services between January 1, 2008 and December 31, 2010. A total of 211 charts were examined for factors including diagnosis given at initial visit, health status, sociodemographic factors and comorbid illnesses, as well as treatment plan prescribed; of these, 132 patients were determined to be depressed at the initial evaluation (Beck Depression Inventory (BDI> 13) and to return for at least one follow-up visit.

RESULTS

Of the 132 depressed patients, 48 (36.4%) reached remission (BDI <13) at some point at follow-up, and an additional 12 (50.7%) achieved response (decrease in BDI of 50%). Remission correlated with having disability income and having a viral load that was not detectable.

CONCLUSIONS

Depression is common in HIV/AIDS, and is important to treat. Furthermore, individuals with depression and HIV/AIDS respond at rates similar to what is seen in other depressed populations.

Comprehensive review of factors implicated in the heterogeneity of response in depression

BACKGROUND

Heterogeneity in overall response and outcomes to pharmacological treatment has been reported in several depression studies but with few sources that integrate these results. The goal of this study was to review the literature and attempt to identify nongenetic factors potentially predictive of overall response to depression treatments.

METHODS

A comprehensive review of the literature from the last 10 years was performed using three key databases (PubMed, EMBASE, and Cochrane). All relevant studies that met the inclusion criteria were selected and scored for their levels of evidence using the NICE scoring method. A subjective assessment of the strength of evidence for each factor was performed using predefined criteria.

RESULTS

Our broad search yielded 76 articles relevant to treatment heterogeneity. Sociodemographic factors, disease characteristics, and comorbidities were the most heavily researched areas. Some of the factors associated with more favorable overall response include being married, other social support, and low levels of baseline depressive symptoms. Evidence relating to baseline disease severity as a factor predictive of antidepressant response was particularly convincing among the factors reviewed. The presence of comorbid anxiety and pain contributed to worse antidepressant treatment outcomes.

CONCLUSIONS

Several factors either predictive of or associated with overall response to antidepressant treatment have been identified. Inclusion of factors predictive of response in the design of future trials may help tailor treatments to depression patients presenting to the average clinical practice, resulting in improved outcomes.

Depression treatment in patients with general medical conditions: results from the CO-MED trial

PURPOSE

We studied the effect of 3 antidepressant treatments on outcomes (depressive severity, medication tolerability, and psychosocial functioning) in depressed patients having comorbid general medical conditions in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial.

METHODS

Adult outpatients who had chronic and/or recurrent major depressive disorder (MDD) with and without general medical conditions were randomly assigned in 1:1:1 ratio to 28 weeks of single-blind, placebo-controlled antidepressant treatment with (1) escitalopram plus placebo, (2) bupropion-SR plus escitalopram, or (3) venlafaxine-XR plus mirtazapine. At weeks 12 and 28, we compared response and tolerability between participants with 0, 1, 2, and 3 or more general medical conditions.

RESULTS

Of the 665 evaluable patients, 49.5% reported having no treated general medical conditions, 23.8% reported having 1, 14.8% reported having 2, and 11.9% reported having at least 3. We found only minimal differences in antidepressant treatment response between these groups having different numbers of conditions; patients with 3 or more conditions reported higher rates of impairment in social and occupational functioning at week 12 but not at week 28. Additionally, we found no significant differences between the 3 antidepressant treatments across these groups.

CONCLUSIONS

Patients with general medical conditions can be safely and effectively treated for MDD with antidepressants with no additional adverse effect or tolerability burden relative to their counterparts without such conditions. Combination therapy is not associated with an increased treatment response beyond that found with traditional monotherapy in patients with MDD, regardless of the presence and number of general medical conditions.

Physical comorbidity and 12-week treatment outcomes in Korean patients with depressive disorders: the CRESCEND study

OBJECTIVE

Physical and depressive disorders frequently co-occur, but effects of physical health on depression treatment outcomes have received little research. This study aimed to compare treatment outcomes between people with depressive disorder with and without comorbid physical disorders.

METHODS

A Korean nationwide sample of 723 people with depressive disorder initiated on antidepressant treatment, and re-evaluated at 1, 2, 4, 8, and 12 weeks later. Assessment scales for evaluating depressive symptoms (HAMD), anxiety (HAMA), global severity (CGI-s), and functioning (SOFAS) were administered at baseline and every follow-up visit. Achievement of remission or response was defined only when these were maintained to the 12 weeks study endpoint or to the last follow-up examination, if earlier, with the date of the first observed remission point applied as the timing of remission. Logistic regression and Cox proportional hazards models were used.

RESULTS

Of the sample, 247 (34%) had at least one physical disorder. This was associated with lower socioeconomic status and more severe depressive symptoms at baseline, but was not associated with any treatment related characteristics including antidepressant type and regimen, concomitant medications, side effects, and duration of treatment period. After adjustment, patients with physical comorbidity responded more slowly and less often - particularly in domains of anxiety, global severity, and functioning (all p-values <.005).

CONCLUSION

More intensive assessment and integrated treatment approaches are needed to facilitate treatment responses for depressive disorders in people with physical comorbidity. Future comparative studies between conventional and integrated treatment approaches are indicated for depressive disorders with physical comorbidity.

Poor response to antidepressant medication of patients with depression accompanied by somatic symptomatology in the STAR*D Study

Studies suggest that the gender difference in the prevalence of depression results because women exhibit higher prevalence than men of a depressive phenotype associated with somatic symptoms. Because this phenotype has been found to be based in psychosocial forces, it may not respond well to antidepressant medication. In this study, data from the STAR*D Study were analyzed to compare remission rates in response to an SSRI and to several other antidepressants of patients exhibiting depression accompanied by somatic symptomatology versus other patients. Scores on the Clinician Rated Quick Inventory of Depressive Symptomatology were used to measure clinical remission in response to medication. Patients exhibiting depression accompanied by somatic symptomatology exhibited less remission to the SSRI Citalopram (31% versus 43%) and to the various medications administered in level 3 (14% versus 25%) than did other patients in STAR*D. The low rates of remission in response to medication of patients exhibiting somatic symptomatology were not due to the greater proportion of women, nor to the greater proportion of patients exhibiting anxiety disorders, among patients exhibiting somatic symptomatology. Remission rates were found to be related to exhibiting somatic symptomatology not to exhibiting nonsomatic symptoms.

The association of major depressive episode and personality traits in patients with fibromyalgia

INTRODUCTION

Personality traits have been associated with primary depression. However, it is not known whether this association takes place in the case of depression comorbid with fibromyalgia.

OBJECTIVE

The authors investigated the association between a current major depressive episode and temperament traits (e.g., harm avoidance).

METHOD

A sample of 69 adult female patients with fibromyalgia was assessed with the Temperament and Character Inventory. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview severity of depressive symptomatology with the Beck Depression Inventory, and anxiety symptomatology with the IDATE-state and pain intensity with a visual analog scale.

RESULTS

A current major depressive episode was diagnosed in 28 (40.5%) of the patients. They presented higher levels of harm avoidance and lower levels of cooperativeness and self-directedness compared with non-depressed patients, which is consistent with the Temperament and Character Inventory profile of subjects with primary depression. However, in contrast to previous results in primary depression, no association between a major depressive episode and self-transcendence was found.

CONCLUSIONS

The results highlight specific features of depression in fibromyalgia subjects and may prove important for enhancing the diagnosis and prognosis of depression in fibromyalgia patients.

Comorbidity of insomnia and depression

During the last decade, several studies have shown that insomnia, rather than a symptom of depression, could be a medical condition on its own, showing high comorbidity with depression. Epidemiological research indicates that insomnia could lead to depression and/or that common causalities underlie the two disorders. Neurobiological and sleep EEG studies suggest that a heightened level of arousal may play a common role in both conditions and that signs of REM sleep disinhibition may appear in individuals prone to depression. The effects of antidepressant drugs on non-REM and REM sleep are discussed in relation to their use in insomnia comorbid with depression. Empirical treatment approaches are behavioral management of sleep combined with prescription of a sedative antidepressant alone, co-prescription of two antidepressants, or of an antidepressant with a hypnotic drug.

Pharmacogenetics studies in STAR*D: strengths, limitations, and results

Several lines of evidence support an important genetic contribution to the wide individual variation in therapeutic response to antidepressant medications. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study provided the largest cohort assembled to date of DNA from patients with nonpsychotic major depressive disorder, uniformly treated with citalopram and followed prospectively for up to 12 weeks. This pivotal study changed the face of pharmacogenetics research by increasing the sample size by an order of magnitude as well as by providing detailed prospective information about antidepressant response and tolerability. Several groups have identified markers in genes and tested the replication of previous findings of genes associated with outcome and side effects of antidepressant treatment. Variants in HTR2A, GRIK4, and KCNK2 were associated with citalopram treatment outcome. Replication was achieved in markers in the FKBP5 gene. Other findings in PDE11A and BDNF were not successfully replicated, and reports of potential confounders in previous associations with serotonin transporter variation (SLC6A4) were identified. Polymorphisms in pharmacokinetic genes involved in metabolism and transmembrane transport were also not associated with antidepressant response. Adverse events were also tested. Treatment-emergent suicidal ideation was associated with GRIK2, GRIA3, PAPLN, IL28RA, and CREB1. Sexual dysfunction was linked with variation in GRIN3A, GRIA1 GRIA3, and GRIK2. Reported and future findings of pharmacogenetics studies in STAR*D could help elucidate pathways involved in major depression and those pertinent to antidepressant outcome and side effects. Replication of these findings in independent samples could lead to the development of new treatments and to optimization of available treatments.

STAR*D: revising conventional wisdom

The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study used a series of sequenced, randomized treatment trials following a first and, if needed, subsequent treatment steps to define the tolerability and effectiveness of various options in both acute and longer term treatment. Adult outpatients (n=4041) with nonpsychotic major depressive disorder, substantial chronic and recurrent depression, and co-morbid psychiatric and general medical conditions were enrolled in 41 representative primary and specialty care settings. About one-third of participants remitted in first step treatment with citalopram, 50% of these within 6 weeks. Poorer outcomes were associated with minority status, socioeconomic disadvantage, more axis I and III co-morbid disorders, lower function and quality of life, and anxious and melancholic features. In step 2 medication switch, there were no significant differences in remission among within-class, out-of-class or dual-action agents: sertraline (27%), bupropion-sustained release (26%) and venlafaxine-extended release (25%). In step 2 medication augmentation of citalopram, there was no significant difference in remission between bupropion-sustained release (39%) and buspirone (33%), although participants using bupropion-sustained release had greater symptom reduction and better tolerability. There were no significant differences in remission in step 2 between cognitive therapy and medication treatment in either the switch (31% vs 27%) or augmentation (31% vs 33%) strategies, although participants in cognitive therapy augmentation had a longer time to remission than those in medication augmentation (55 vs 40 days). In step 3, there were no differences in remission between a switch to mirtazapine (8%) or nortriptyline (12%), or between augmentation with lithium (13%) or T(3) (triiodothyronine, liothyronine) [25%], although more participants discontinued lithium due to adverse effects than discontinued T(3). In the fourth step, there was no difference in remission between tranylcypromine (14%) or venlafaxine-extended release plus mirtazapine (16%), although the combination treatment had fewer adverse effects and had the advantages of not requiring a washout period or diet restrictions. Participants requiring more than two well delivered treatments may be characterized as treatment resistant given the substantially lower remission rates after that point. Treatment resistance was associated with more concurrent axis I or III co-morbid conditions, socioeconomic disadvantage, chronicity and melancholic or anxious features. However, if participants remained in treatment for up to four steps, about 67% reached remission. Times to remission were not substantially longer for later treatment steps. The importance of reaching remission is highlighted by the lower relapse rates in naturalistic follow-up for participants entering in remission compared with those entering with response but not remission (step 1: 34% vs 59%; step 2: 47% vs 68%; step 3: 42% vs 76%; step 4: 50% vs 83%). Clinical decision making based on the itemized measurement of symptoms and adverse effects at each treatment visit was feasible in STAR*D's real world settings and resulted in adequate dosages and durations of treatment that generally exceeded those typically found in practice settings. Although switch and augmentation strategies could not be directly compared due to the equipoise stratified randomized design, the higher remission rates at step 2 with medication augmentation are intriguing and merit further study.

Comorbidity of cardiovascular diseases with mood and anxiety disorder: a population based 4-year study

AIMS

Accumulating evidence from Caucasian patients has shown that depression, bipolar and anxiety disorders are associated with an increased risk of cardiovascular diseases (CVD), but reports in the Asian population are limited, and age effect is rarely investigated. This population-based study was carried out to examine and compare the CVD comorbidities among patients with mood and anxiety disorders in different age groups.

METHOD

A 4-year cross-sectional survey was carried out using the Taiwan National Health Insurance Research Database from 2000 to 2003.

RESULTS

An average total of 1,031,557 patients with mood and anxiety disorders were enrolled as study participants, including 76,430 cases of major depressive disorder, 41,557 cases of bipolar disorder, and 913,570 cases of anxiety disorder. When compared with the insured population without mood or anxiety disorders (average 21,356,304 people), the average relative risk (RR) of developing ischemic heart disease and hypertensive disorders in 1,031,557 study participants was 2.0 and 2.05, respectively. The highest RR was found in the age group under 20 years (RR = 4.74 and 4.08, respectively), and the lowest RR in the age group equal to or older than 65 years (RR = 0.47 and 0.58, respectively).

CONCLUSIONS

Taiwanese patients with mood and anxiety disorders experience high cardiovascular morbidity, especially patients with anxiety disorders. Age acted as an important modifier variable that influenced the relationship between mood, anxiety disorder and CVD. This study highlights the need for future research in different age groups, in order to elucidate the causality and the trajectory of developing CVD among patients with mental disorders.

Sleep disorders as core symptoms of depression

Links between sleep and depression are strong. About three quarters of depressed patients have insomnia symptoms, and hypersomnia is present in about 40% of young depressed adults and 10% of older patients, with a preponderance in females. The symptoms cause huge distress, have a major impact on quality of life, and are a strong risk factor for suicide. As well as the subjective experience of sleep symptoms, there are well-documented changes in objective sleep architecture in depression. Mechanisms of sleep regulation and how they might be disturbed in depression are discussed. The sleep symptoms are often unresolved by treatment, and confer a greater risk of relapse and recurrence. Epidemiological studies have pointed out that insomnia in nondepressed subjects is a risk factor for later development of depression. There is therefore a need for more successful management of sleep disturbance in depression, in order to improve quality of life in these patients and reduce an important factor in depressive relapse and recurrence.

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity

BACKGROUND

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.

OBJECTIVE

To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.

DESIGN

Secondary analysis from the Quality Improvement in Depression Study dataset.

PARTICIPANTS

The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.

MEASUREMENTS

Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.

RESULTS

Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).

CONCLUSIONS

Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

Depression in the medically ill: diagnostic and therapeutic implications

Depression and medical comorbidities lead to increased morbidity and mortality and have been associated with higher health care costs. Depressive disorders can adversely impact the course of medical illnesses, whereas medical illnesses can serve as a risk factor for future depressive disorders. This interplay has spurred some interesting exploratory research to understand the common pathophysiology and neurobiologic substrates that may explain the bidirectional relationship between the two disorders. There is a paucity of well-designed, randomized, controlled trials to address some of the treatment-related prognostic issues in this population. However, more recent studies have focused on diagnostic and treatment implications with various available pharmacologic and psychotherapeutic modalities. Early identification and appropriate treatment of depression in the medically ill can positively influence medical outcomes and quality of life. Collaborative care models integrating mental health and primary care providers, combined with patient preference, are found to be cost-effective and may result in better response to depression treatment.

Organization of brain somatomotor-sympathetic circuits

Numerous physiological and emotionally motivated behaviors require concomitant activation of somatomotor and sympathetic efferents. Likewise, adaptive and maladaptive responses to stress are often characterized by simultaneous recruitment of these efferent systems. This review describes recent literature that outlines the organization of somatomotor-sympathetic circuitry in the rat. These circuits were delineated by employing recombinant pseudorabies (PRV) viral vectors as retrograde trans-synaptic tract tracers. In these studies PRV-152, a strain that expresses enhanced green fluorescent protein, was injected into sympathectomized hindlimb muscle, while PRV-BaBlu, which expresses beta-galactosidase, was injected into the adrenal gland in the same animals. Immunofluorescent methods were then used to determine the presence of putative dual-function neurons that were infected with both viral strains. These somatomotor-sympathetic neurons (SMSNs) were detected in a number of brain regions. However, the most prominent nodes in this circuitry included the paraventricular, dorsomedial, and lateral nuclei of the hypothalamus, ventrolateral periaqueductal grey and ventromedial medulla. Phenotypic studies revealed subsets of SMSNs to be capable of synthesizing serotonin, or to contain neuroactive peptides vasopressin, oxytocin, orexins, or melanin-concentrating hormone. Based on these data and the results of studies employing monosynaptic tracers a central somatomotor-sympathetic circuit is proposed. This circuitry is likely recruited in diverse situations, including stress responses, cold defense, exercise and sleep. Furthermore, activation of specific classes of SMSNs likely shapes distinct stress-coping strategies. Dysregulation in the organization and function of this circuit may also contribute to the expression of physical symptoms of affective disorders, such as major depression, anxiety and panic.