Akbaraly, T. N., E. J. Brunner, et al. (2009). "Dietary pattern and depressive symptoms in middle age." The British Journal of Psychiatry 195(5): 408-413. http://bjp.rcpsych.org/cgi/content/abstract/195/5/408
Background: Studies of diet and depression have focused primarily on individual nutrients. Aims: To examine the association between dietary patterns and depression using an overall diet approach. Method: Analyses were carried on data from 3486 participants (26.2% women, mean age 55.6 years) from the Whitehall II prospective cohort, in which two dietary patterns were identified: whole food' (heavily loaded by vegetables, fruits and fish) and processed food' (heavily loaded by sweetened desserts, fried food, processed meat, refined grains and high-fat dairy products). Self-reported depression was assessed 5 years later using the Center for Epidemiologic Studies - Depression (CES-D) scale. Results: After adjusting for potential confounders, participants in the highest tertile of the whole food pattern had lower odds of CES-D depression (OR = 0.74, 95% CI 0.56-0.99) than those in the lowest tertile. In contrast, high consumption of processed food was associated with an increased odds of CES-D depression (OR = 1.58, 95% CI 1.11-2.23). Conclusions: In middle-aged participants, a processed food dietary pattern is a risk factor for CES-D depression 5 years later, whereas a whole food pattern is protective.
Bandolier (2009) Assessing relative efficacy of antidepressants. Bandolier.
This is Bandolier's commentary on: A Cipriani et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 2009 373: 748-758. They wrote that the clinical bottom line is that: Analysis of large numbers of trials in depression show that some drugs (sertraline, escitalopram, for example) do better than others in terms of both reducing depression scores in more people, and being more acceptable, so that more people are able to take the drugs. These properties probably go together. While this is far from the whole story, there is important information to begin constructing useful care pathways designed to treat more people effectively at lowest cost and least hassle for all. Well worth clicking on the link to read the whole freely viewable article.
Clark, D. M., R. Layard, et al. (2009). "Improving access to psychological therapy: Initial evaluation of two UK demonstration sites." Behav Res Ther 47(11): 910-20. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19647230
Recently the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders. Prior to this development, the Department of Health established two pilot projects that aimed to collect valuable information to inform the national roll-out. Doncaster and Newham received additional funds to rapidly increase the availability of CBT-related interventions and to deploy them in new clinical services, operating on stepped-care principles, when appropriate. This article reports an evaluation of the new services (termed 'demonstration sites') during their first thirteen months of operation. A session-by-session outcome monitoring system achieved unusually high levels of pre to post-treatment data completeness. Large numbers of patients were treated, with low-intensity interventions (such as guided self-help) being particularly helpful for achieving high throughput. Clinical outcomes were broadly in line with expectation. 55-56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status. Treatment gains were largely maintained at 10 month follow-up. Opening the services to self-referral appeared to facilitate access for some groups that tend to be underrepresented in general practice referrals. Outcomes were comparable for the different ethnic groups who access the services. Issues for the further development of IAPT are discussed.
Coryell, W., D. A. Solomon, et al. (2009). "Anxiety and Outcome in Bipolar Disorder." Am J Psychiatry 166(11): 1238-1243. http://ajp.psychiatryonline.org/cgi/content/abstract/166/11/1238
OBJECTIVE: Important differences exist between bipolar disorder with and without comorbid anxiety, but little is known about the long-term prognostic significance of coexisting anxiety in bipolar disorder. The authors sought to identify the anxiety features most predictive of subsequent affective morbidity and to evaluate the persistence of the prognostic relationship. METHOD: Probands with bipolar I or II disorder from the National Institute of Mental Health Collaborative Depression Study were followed prospectively for a mean of 17.4 years (SD=8.4) and were characterized according to various manifestations of anxiety present at baseline. A series of general linear model analyses examined the relationship between these measures and the proportion of follow-up weeks in episodes of major depression and in episodes of mania or hypomania. RESULTS: Patients whose episode at intake included a depressive phase spent nearly three times as many weeks in depressive episodes than did those whose intake episode was purely manic. Psychic and somatic anxiety ratings, but not the presence of panic attacks or of any lifetime anxiety disorder, added to the predictive model. Combined ratings of psychic and somatic anxiety were associated in a stepwise fashion with a greater proportion of weeks in depressive episodes, and this relationship persisted over the follow-up period. CONCLUSIONS: The presence of higher levels of anxiety during bipolar mood episodes appears to mark an illness of substantially greater long-term depressive morbidity.
Fergusson, D. M., L. J. Horwood, et al. (2009). "Reactions to abortion and subsequent mental health." The British Journal of Psychiatry 195(5): 420-426. http://bjp.rcpsych.org/cgi/content/abstract/195/5/420
Background: There has been continued interest in the extent to which women have positive and negative reactions to abortion. Aims: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes. Method: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30. Results: Abortion was associated with high rates of both positive and negative emotional reactions; however, nearly 90% of respondents believed that the abortion was the right decision. Analyses showed that the number of negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05). Further analyses suggested that, after adjustment for confounding, those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion. Conclusions: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.
Gaynes, B. N., D. Warden, et al. (2009). "What Did STAR*D Teach Us? Results From a Large-Scale, Practical, Clinical Trial for Patients With Depression." Psychiatr Serv 60(11): 1439-1445. http://ps.psychiatryonline.org/cgi/content/abstract/60/11/1439
The authors provide an overview of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a large-scale practical clinical trial to determine which of several treatments are the most effective "next-steps" for patients with major depressive disorder whose symptoms do not remit or who cannot tolerate an initial treatment and, if needed, ensuing treatments. Entry criteria were broadly defined and inclusive, and patients were enrolled from psychiatric and primary care clinics. All participants began on citalopram and were managed by clinic physicians, who followed an algorithm-guided acute-phase treatment through five visits over 12 weeks. At the end of each sequence, patients whose depression had not fully remitted were eligible for subsequent randomized trials in a sequence of up to three clinical trials. In general, remission rates in the study clinics were lower than expected, suggesting the need for several steps to achieve remission for most patients. There was no clear medication "winner" for patients whose depression did not remit after one or more aggressive medication trials. Both switching and augmenting appeared to be reasonable options when an initial antidepressant treatment failed, although these two strategies could not be directly compared. Further, the likelihood of remission after two vigorous medication trials substantially decreased, and remission would likely require more complicated medication regimens for which the existing evidence base is quite thin. STAR*D demonstrated that inclusion of more real-world patients in clinical trials is both feasible and informative. Policy implications of the findings, as well as the study's limitations, are discussed.
Horowitz, J. A., C. A. Murphy, et al. (2009). "Best Practices: Community-Based Postpartum Depression Screening: Results From the CARE Study." Psychiatr Serv 60(11): 1432-1434. http://ps.psychiatryonline.org/cgi/content/abstract/60/11/1432
This column describes findings and best-practice recommendations from CARE (Communicating and Relating Effectively), a prospective randomized study in which 5,169 mothers were screened for postpartum depression. The prevalence rate was 13%. Results support use of the Edinburgh Postnatal Depression Screening Scale and a diagnostic assessment for those who screen positive. Of the 674 mothers with positive screens, 26% were not asked about their emotional state by clinicians. Screening must be linked to treatment options via referral and follow-up. Best-practice strategies for implementing screening include educating clinicians and postpartum women.
Howren, M. B., J. Suls, et al. (2009). "Depressive Symptomatology, Rather than Neuroticism, Predicts Inflated Physical Symptom Reports in Community-Residing Women." Psychosom Med 71(9): 951-957. http://www.psychosomaticmedicine.org/cgi/content/abstract/71/9/951
Objective: To examine the roles of depressive symptomatology and neuroticism/negative affect (N/NA) on common physical symptom reporting in a sample of community residents. Methods: Community-residing women (n = 108) participated in a combined concurrent-retrospective design. Physical symptoms were assessed concurrently over 21 consecutive days followed by a retrospective assessment of the collective symptom experience for the same time period. Results: Based on evidence of differences in cognitive processing of emotion-relevant material, we predicted and found that depressive symptomatology (at baseline) was a stronger predictor of inflated physical symptom recall than N/NA. Depressive symptomatology was also a stronger, independent predictor of concurrent physical symptoms. Notably, these results were obtained even when physical depressive symptoms in both the physical symptom checklist and the baseline depression assessment were eliminated. Conclusions: The results suggest that the classic symptom perception hypothesis should be refined and operationalized in terms of depressive symptomatology rather than N/NA. This study demonstrates how cognitive-affective processing differences associated with depressive symptomatology can shed additional light on the psychology of symptom perception. Implications for treatment seeking, medical diagnoses, and treatment decisions are discussed.
Insel, T. R. and P. S. Wang (2009). "The STAR*D Trial: Revealing the Need for Better Treatments." Psychiatr Serv 60(11): 1466-1467. http://ps.psychiatryonline.org/cgi/content/abstract/60/11/1466
STAR*D (Sequenced Treatment Alternatives to Relieve Depression) continues to stimulate debate. The landmark trial demonstrated the feasibility of large-scale, community-based studies conducted without pharmaceutical company support. The results provided insight into nonresponse to initial treatment with selective serotonin reuptake inhibitors and alternatives for second- and third-line treatment options and suggested opportunities for personalized approaches to depression care. However, initial and one-year remission rates (28% and 70%, respectively) suggest that important goals for treatment of this disabling disease remain out of reach and that the bar for antidepressants has been set far too low.
Kelley, J. C. (2009) “No Added Benefit of Adjunctive Psychotherapy to Antidepressants Alone in Chronic Depression.” Medscape Psychiatry & Mental Health.
Adjunctive psychotherapy in combination with antidepressant medication appears to offer no additional therapeutic benefit in patients with chronic depression, a large, randomized, 12-week trial suggests. Investigators at Weill Cornell Medical College in New York found that after 12 weeks of continued pharmacotherapy plus either brief supportive psychotherapy (BSP) or cognitive behavioral analysis system of psychotherapy (CBASP), outcomes were no better than if patients received medication alone. "It would be fair to say that the approaches were equally effective," lead investigator James H. Kocsis, MD, told Medscape Psychiatry. The study is published in the November issue of Archives of General Psychiatry. Findings Contrary to Study Hypothesis: The trial included 491 patients with chronic depression. Participants had depressive symptoms for a minimum of 2 years without remission and met diagnostic criteria for double depression, chronic major depression, or recurrent major depression with incomplete recovery between episodes. The study's main outcome measures were proportion of remitters, partial remitters, and nonresponders and change from baseline in the Hamilton Scale for Depression scores. Participants were randomized to receive 12 weeks of continued pharmacotherapy plus CBASP, continued pharmacotherapy with BSP, or continued optimized pharmacotherapy alone. At the end of the study period, the investigators found no statistically significant differences among the 3 treatment groups in the proportions of patients in remission, partial response, or nonresponse, suggesting, said Dr. Kocsis, that although chronic depression is often helped by medication, there is little evidence of added benefit with adjunctive psychotherapy. "We were surprised. The results went against our hypotheses. We are interested in studying differential predictors of response to drugs versus psychotherapy. We think early life adversity and childhood maltreatment may be important in predicting need for psychotherapy," Dr. Kocsis said. Dr. Kocsis also noted that current American Psychiatric Association treatment guidelines only address major depression and not chronic depression. "Perhaps they should develop separate guidelines for chronic depression," he said. Convincing but Not Conclusive: Pim Cuijpers, PhD, who has published 2 meta-analyses of psychotherapies for chronic depression, described the Kocsis study as "sobering." Dr. Cuijpers is professor of clinical psychology, chair of the Department of Clinical Psychology, and vice-director of the EMGO Institute for Health and Care Research at VU University, Amsterdam, The Netherlands. Dr. Cuijpers told Medscape Psychiatry that, although he finds these data convincing, they are not conclusive. "The conclusion that pharmacotherapy alone is just as good as combined treatments is not supported by the total body of research in this area," he said.
The Cuijpers' meta-analysis of psychotherapies for chronic depression, which is currently in press, concluded that combined treatments have a small benefit over pharmacotherapy alone.
"I do not think the Kocsis study [which was published after the meta-analysis was completed] would change the results of our meta-analysis if it had been included. Our meta-analysis, however, also shows that the results of psychotherapy are not very high in chronic depression," Dr. Cuijpers said.
Kocsis, J. H., A. J. Gelenberg, et al. (2009). "Cognitive Behavioral Analysis System of Psychotherapy and Brief Supportive Psychotherapy for Augmentation of Antidepressant Nonresponse in Chronic Depression: The REVAMP Trial." Arch Gen Psychiatry 66(11): 1178-1188. http://archpsyc.ama-assn.org/cgi/content/abstract/66/11/1178
Context Previous studies have found that few chronically depressed patients remit with antidepressant medications alone. Objective To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial. Design This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone. Setting Eight academic sites. Participants Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years. Interventions Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs). Main Outcome Measures Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores. Results In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores. Conclusions Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing.
Kovacs, M., J. Rottenberg, et al. (2009). "Maladaptive mood repair responses distinguish young adults with early-onset depressive disorders and predict future depression outcomes." Psychological Medicine 39(11): 1841-1854. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6292416&fulltextType=RA&fileId=S0033291709005789
Background: Clinical depression involves persistent dysphoria, implicating impaired affect regulation or mood repair failure. However, there is comparatively little information about the mood repair repertoires of individuals with histories of clinical depression, how their repertories differ from that of never-depressed people, and whether particular types of mood repair responses differentially contribute to depression risk. Method: Adult probands who had childhood-onset depressive disorder (n=215) and controls with no history of major mental disorder (n=122) reported which specific (cognitive, behavioral, interpersonal and somatic-sensory) responses they typically deploy when experiencing sad affect, including responses known to appropriately attenuate dysphoria ( responses) and those known to exacerbate dysphoria in the short or long run ( responses). Subjects were longitudinally followed and evaluated. Results: Remitted probands and probands in depressive episodes both reported a greater number of maladaptive responses and fewer adaptive responses to their own sadness than did controls, although probands did not have an absolute deficiency of adaptive responses. Maladaptive (but not adaptive) mood repair responses predicted future increases in depression symptoms and an increased probability of a recurrent depressive episode among probands (even after controlling for several clinical predictors of course). Post-hoc analyses revealed that maladaptive non-cognitive and maladaptive cognitive mood repair response sets each predicted depression outcomes. Conclusions: Individuals with past and present episodes of depressive disorder report an array of cognitive and non-cognitive responses to their own sadness that are likely to exacerbate that affect, and this pattern predicts a worse course of the disorder.
Qin, P., P. Jepsen, et al. (2009). "Hospital admission for non-fatal poisoning with weak analgesics and risk for subsequent suicide: a population study." Psychological Medicine 39(11): 1867-1873. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6292404&fulltextType=RA&fileId=S0033291709005741
Background: Poisoning with weak analgesics is a major public health problem because of easy accessibility of the compounds; however, few studies have investigated their influence on subsequent suicide in the context of subjects' psychiatric status and other factors. Method: This nested case-control study was based on the entire Danish population including all 21 169 suicide cases and 423 128 matched population controls. Data on hospital admissions for poisoning and confounding factors were retrieved from national medical and administrative registries. Conditional logistic regression was used to compute relative risk. Results; A prior hospital admission for poisoning with weak non-opioid analgesics significantly increased the risk of subsequent suicide [crude incidence rate ratio (IRR) 24.7, 95% confidence interval (CI) 22.13139.1), then declined over time but still remained significantly high 3 years later (adjusted IRR 4.2, 95% CI 3.5–5.0). Moreover, a history of weak analgesic poisoning significantly interacted with a person's psychiatric history, increasing the risk for subsequent suicide substantially more for persons with no history of psychiatric hospitalization than did it for those with such a history. Conclusions: A history of non-fatal poisoning with weak analgesics is a strong predictor for subsequent suicide. These results emphasize the importance of intensive psychiatric care of patients following overdose.
Shern, D. L. and H. Moran (2009). "STAR*D: Helping to Close the Gap Between Science and Practice." Psychiatr Serv 60(11): 1458-1459. http://ps.psychiatryonline.org/cgi/content/abstract/60/11/1458
Practical clinical trials, such as STAR*D (Sequenced Treatment Alternatives to Relieve Depression), extend the traditional randomized controlled trial to real-world settings. Consumers and clinicians should be encouraged by STAR*D's 70% remission rate and should realize that for many participants remission required medication switching and augmentation. Policy makers should recognize the importance of easy access to a full range of treatments. Researchers should be sobered by the high attrition rate and the 30% of participants who did not achieve remission. Although more such practical trials are needed, future work must more meaningfully involve consumers in design, analysis, and interpretation.