Long-term treatment of severe depression

Guideline-Consistent Antidepressant Treatment Patterns Among Veterans With Diabetes and Major Depressive Disorder

Depression is associated with more rapid cognitive decline in Parkinson's disease (PD).The goal of this study was to examine the impact of the acute (8-week) and longer-term (24-week) antidepressant treatment on cognition in PD and to detail cognitive predictors of treatment response.Fifty-two depressed PD patients were enrolled in an NIH funded randomized-controlled trial of nortriptyline, paroxetine, and placebo.Neuropsychological testing was performed at baseline, and weeks eight and twenty-four.Higher baseline scores on measures of executive functioning, speed of processing, and verbal memory were associated with antidepressant response.Treatment responders did not exhibit larger gains in cognition than non-responders.Findings warrant replication.

Changes in Regional Cerebral Blood Flow After Repetitive Transcranial Magnetic Stimulation of the Left Dorsolateral Prefrontal Cortex in Treatment-Resistant Depression

Treatments for major depression – Authors' reply

Objectives The objective of this review was to present the best available information on the use of cognitive behaviour therapy using either group cognitive therapy (GCT) or individual cognitive therapy (ICT) in the treatment of depression. The primary question to be addressed in this review was: For the treatment of long-term depression, using a cognitive behavioural approach, is group therapy or individual therapy the most effective? Inclusion criteria Studies that included adolescents or adults with long-term depression and a measured Beck Depression Inventory (BDI) value of ≥12 or Hamilton Rating Scale for Depression (HRSD) of ≥14 were included. Interventions of interest were forms of cognitive behaviour therapy utilising either an individual or group approach. For the purpose of this review individual therapy was regarded as a one-to-one interaction between the patient and the therapist. Group therapy excluded family therapy. This review excluded studies that involved pharmacotherapy alone as the only intervention and studies that involved combined group and individual treatment. Outcome measures of interest were reduction in depression inventory scores, specifically the BDI and/or the HRSD. This study considered any randomised or pseudo-randomised controlled trials that addressed the use or comparison of GCT or ICT. Results Individual and group cognitive behavioural therapies for moderately or severely depressed adults (BDI ≥ 14) were comparable with each other in effectiveness and both were superior to providing no treatment at all. Individual cognitive therapy was equal to or better than tricyclic antidepressant drugs given at recommended therapeutic dosages for depressed people with a mean BDI of 30. This information was based on level II evidence. Recommendations The following recommendations were made for adults: 1 Either GCT or ICT can be used to treat moderate to severe depression. The choice of therapy should be dependent upon the clinician's perceived receptiveness of the particular patient to group or individual treatment. 2 The use of computer-assisted therapy is a useful adjunct to GCT in moderate to severely depressed patients. 3 ICT can effectively replace pharmacotherapy in moderate to severely depressed patients if the patient is opposed to being treated with drug therapy. 4 GCT has not been compared to pharmacotherapy so no direct recommendation can be given as to its effectiveness as a replacement therapy. The following recommendations were made for adolescents: 1 Either GCT or ICT can be used to treat moderately depressed adolescents (BDI ≥ 14). 2 More research is needed to determine the effectiveness of GCT or ICT in severely depressed adolescents (BDI ≥ 20).

The objective of this review was to present the best available information on the use of cognitive behaviour therapy using either group cognitive therapy (GCT) or individual cognitive therapy (ICT) in the treatment of depression. The primary question to be addressed in this review was: For the treatment of long-term depression, using a cognitive behavioural approach, is group therapy or individual therapy the most effective? Studies that included adolescents or adults with long-term depression and a measured Beck Depression Inventory (BDI) value of ≥12 or Hamilton Rating Scale for Depression (HRSD) of ≥14 were included. Interventions of interest were forms of cognitive behaviour therapy utilising either an individual or group approach. For the purpose of this review individual therapy was regarded as a one-to-one interaction between the patient and the therapist. Group therapy excluded family therapy. This review excluded studies that involved pharmacotherapy alone as the only intervention and studies that involved combined group and individual treatment. Outcome measures of interest were reduction in depression inventory scores, specifically the BDI and/or the HRSD. This study considered any randomised or pseudo-randomised controlled trials that addressed the use or comparison of GCT or ICT. Individual and group cognitive behavioural therapies for moderately or severely depressed adults (BDI ≥ 14) were comparable with each other in effectiveness and both were superior to providing no treatment at all. Individual cognitive therapy was equal to or better than tricyclic antidepressant drugs given at recommended therapeutic dosages for depressed people with a mean BDI of 30. This information was based on level II evidence. The following recommendations were made for adults:1 Either GCT or ICT can be used to treat moderate to severe depression. The choice of therapy should be dependent upon the clinician's perceived receptiveness of the particular patient to group or individual treatment.2 The use of computer-assisted therapy is a useful adjunct to GCT in moderate to severely depressed patients.3 ICT can effectively replace pharmacotherapy in moderate to severely depressed patients if the patient is opposed to being treated with drug therapy.4 GCT has not been compared to pharmacotherapy so no direct recommendation can be given as to its effectiveness as a replacement therapy.The following recommendations were made for adolescents:1 Either GCT or ICT can be used to treat moderately depressed adolescents (BDI ≥ 14).2 More research is needed to determine the effectiveness of GCT or ICT in severely depressed adolescents (BDI ≥ 20).

Cognitive behavior therapy (CBT) is a pragmatic, action-oriented treatment approach that has become a widely used psychotherapy for major mental disorders. CBT methods were initially developed for depression and anxiety disorders (1–3), and later they were modified for many other conditions, including personality disorders, eating disorders, and substance abuse; they have also been adapted for use as an adjunct to medication in the management of schizophrenia and bipolar disorder (3, 4–7). This article delineates the core principles of CBT, describes procedures used in clinical practice, and notes some of the recent advances that have been made in this treatment method. The extensive research supporting the efficacy of CBT is briefly reviewed.

The Neglected Role of Psychotherapy for Treatment-Resistant Depression.

“Ms. A” was a 35-year-old married Caucasian health care professional with a history of recurrent major depressive disorder that responded well to treatment with a selective serotonin reuptake inhibitor (SSRI). She discontinued her antidepressant prior to conception for a planned pregnancy because she did not want to expose her baby to medication. She soon relapsed, and by the first trimester of her pregnancy, she was in a major depressive episode. Her symptoms included anhedonia, tearfulness, irritability, insomnia, and diminished appetite. She presented for participation in an open-label pilot trial of omega-3 fatty acids for antenatal major depressive disorder (1). At intake, after hearing the risks and benefits of available treatment options, Ms. A declined antidepressant medication and a referral for psychotherapy and consented to participate in the study of omega-3 fatty acids, which she started at 16 weeks’ gestation. She was assessed every 2 weeks throughout pregnancy. At 8 weeks she had not responded to omega-3 fatty acids and was again presented with other treatment options, including medication and psychotherapy. She again declined these treatments and continued to do so throughout the remainder of her pregnancy. She was concerned about the safety of medications in pregnancy and believed that taking medication would make her a bad mother. She also declined referral for psychotherapy, stating that she was “too busy.”

Child and adolescent depression is a serious and often episodic disorder with a high rate of recurrence equal to or surpassing that of adult depression. Symptoms of depression are similar in child, adolescent, and adult populations. The diagnostic criteria are the same, with the possible exception that children and adolescents are more likely to present with irritability without clear sadness. Despite the similarities between adult, adolescent, and child depression, results of studies of psychosocial and pharmacologic treatments in adult depression are not necessarily applicable to the pediatric population. The treatment of depression has been divided into three phases: acute (leading to clinical response and remission of symptoms); continuation (prevention of symptom relapse); and maintenance (prevention of new episodes or recurrences). According to research of acute treatment of child and adolescent depression with pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment. Recent controversies have caused some concern about the use of SSRIs in children and adolescents; however, SSRIs remain the initial pharmacologic treatment of choice. Acute treatment with non-specific psychotherapy is considered an essential component in the management of depression, but has not been shown to be equally effective as pharmacotherapy or specific psychotherapies by itself. There is increasing evidence that cognitive behavior therapy and interpersonal therapy are effective for the treatment of early-onset depression. Unfortunately, severe depression, comorbid diagnoses, family discord, and increased impairment may hinder the establishment of remission; these factors have been associated with treatment resistance. Once remission of depressive symptoms is established, continuation and maintenance treatment should be considered. Only one study of continuation treatment has been completed in child and adolescent depression; the results support the use of fluoxetine as a safe and effective treatment for reducing relapse. To date, no studies have been reported on maintenance treatment with specific therapies in child and adolescent depression, but trials in adults have demonstrated the importance of continued pharmacotherapy beyond the continuation phase of the illness. Although several factors are associated with response to treatment in children and adolescents with depression, including younger age, lower severity of depressive symptoms, higher family functioning, and fewer comorbid diagnoses, few studies have consistently demonstrated predictors of relapse and recurrence.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessStudies Link Depression Treatment To Clinical OutcomesEve BenderEve BenderPublished Online:4 Jul 2003https://doi.org/10.1176/pn.38.13.0016APA's American Psychiatric Institute for Research and Education (APIRE) is piloting two new studies in real-world settings to evaluate the cost and quality of the treatments that psychiatrists use for depression and link those treatments with clinical outcomes in patients.Beginning this month, APIRE reasearchers are surveying both psychiatrist members of APA's Practice Research Network (PRN) and a sample of their patients -the latter for the first time.The PRN is a network of 726 practicing psychiatrists established in 1993. Half of the network members volunteer to participate in studies conducted by PRN staff, and half have been randomly sampled from a database of the AMA and asked to participate in the studies.The researchers will collect longitudinal patient data within small samples initially to test the strength of survey methods before launching large-scale studies. Both studies employ strict informed-consent procedures for study participants and comply with federal privacy safeguards, according to APIRE researchers.In the study, titled "Clinical Effectiveness of Treatments for Depression," researchers ask psychiatrists to complete an "elicitation of outcomes" form, in which they predict outcomes for a group of hypothetical patients with severe depression and certain demographic characteristics.Darrel Regier, M.D., M.P.H.: "What we don't know yet is whether the clinical trials literature matches with the outcomes that routine psychiatric practice produces.""It's important to know how psychiatrists rate the treatments available to treat depression, because they are the ones who decide which treatments the patients receive," co-principal investigator Maritza Rubio-Stipec, Ph.D., told Psychiatric News.The outcomes questions are modeled after those used by Richard Frank, Ph.D., a professor of health care economics at Harvard, according to Rubio-Stipec. Frank, using his Price Indexes for the Treatment of Depression, calculates indexes for the cost of outpatient treatment for an episode of major depression.Frank bases his estimates on the expertise of a 10-member panel that reviews the literature on patients who have major depression and enter clinical trials and rates the treatments by predicting what outcomes they will bring about in patients."What we're trying to do," said co-principal investigator and APIRE Executive Director Darrel Regier, M.D., M.P.H., "is see whether outcomes in psychiatric settings reflect those projected by the expert panel."Regier, who served as an expert on Frank's panel, said that if the PRN findings validate the panel's predictions about treatment outcomes, Frank would then be able to price outpatient treatments for depression more confidently.Regier and Rubio-Stipec, as part of their study, will compare the predicted outcomes for hypothetical patients with actual outcomes provided by the patients, who complete a Hamilton-Depression scale (HAMD) at baseline and at 10 weeks.Psychiatrists also provide information about the patient by completing baseline and follow-up surveys.The follow-up information will enable the researchers, in the large-scale study, to compare the outcomes forecast by the psychiatrists at the outset of the study to actual patient outcomes."It is essential to obtain data on what types of outcomes are resulting from treatment strategies that are used each day in the practice of psychiatry," Regier added. "The general public doesn't have a sense of how good the treatments for depression are in comparison with treatments for other medical conditions."Also, this month APIRE staff are launching the study "Outcomes of Psychiatric Treatment for Adolescent Depression" to learn more about the treatment strategies psychiatrists are using for adolescents with major depression and how well those treatments are working."What is unique about this study is that we are using multiple informants and gathering longitudinal data on the adolescents in our sample," said principal investigator William Narrow, M.D., director of APIRE's psychopathology research program.Narrow explained that there is insufficient research on depressed children and adolescents, and all too often treatments for depression in the younger generations are based upon the findings from studies of adults with depression.Narrow and Farifteh Duffy, Ph.D., a coprincipal investigator and APIRE research scientist, will gather information about adolescents with depression from three sources: psychiatrists, who provide information about patients' clinical characteristics, functioning level, and treatments; adolescent patients, who provide information about symptoms, feelings, and aspects of school and family life; and the adolescents' primary caregivers, who answer questions about their relationship with the patient and share observations about the patient's behavior and treatment compliance, for instance.Psychiatrists complete a brief form at each patient visit to keep the researchers abreast of changes in the patient's treatment or clinical status between the baseline assessment and the final follow-up survey, two months later.Psychiatrists, patients, and caregivers also complete follow-up surveys on topics ranging from clinical status and treatment compliance to satisfaction with treatment.According to Duffy, the study "describes the treatments used in routine psychiatric practice for adolescents with depression and allows us to understand better the extent to which these treatments conform to existing treatment guidelines."Narrow said the researchers will pay close attention to predictors of good outcomes in the adolescents, as well as "predictors of poor outcomes that may be modifiable -in this case, we would have a basis for an intervention-to enhance good outcomes or prevent poor ones."More information about the APIRE studies is available by calling (800) 713-7123. ▪ ISSUES New Archived

Treatment of depression in Parkinson's disease

Modern community-based studies have revealed high prevalence rates for major depression in adults. Despite this high prevalence, many depressed individuals do not seek treatment and only a minority of those that do are prescribed antidepressants. This paper considers the role of antidepressants, especially of milnacipran in the treatment of major depression. Milnacipran inhibits the reuptake of serotonin and noradrenaline (SNRI) in a selective manner without affecting various postsynaptic receptor sites; this results in a favourable tolerability profile of the drug. Minimising adverse events is important to enhance patient compliance and facilitate the administration of therapeutic doses of antidepressants. Data from placebo-controlled trials and the results of comparator studies involving TCAs and SSRIs have confirmed that milnacipran is an effective and well tolerated antidepressant, particularly useful in patients with severe depression. A recent pharmacoeconomic study has confirmed that milnacipran is a cost effective alternative to TCAs and SSRIs in the treatment of severe depression. © 1997 John Wiley & Sons, Ltd.

The aim of this document is to provide evidence-based recommendations for the medical treatment of depression in adults with epilepsy. The working group consisted of members of an ad hoc Task Force of the International League Against Epilepsy (ILAE) Commission on Psychiatry, ILAE Executive and the International Bureau for Epilepsy (IBE) representatives. The development of these recommendations is based on a systematic review of studies on the treatment of depression in adults with epilepsy, and a formal adaptation process of existing guidelines and recommendations of treatment of depression outside epilepsy using the ADAPTE process. The systematic review identified 11 studies on drug treatments (788 participants, class of evidence III and IV); 13 studies on psychological treatments (998 participants, class of evidence II, III and IV); and 2 studies comparing sertraline with cognitive behavioral therapy (CBT; 155 participants, class of evidence I and IV). The ADAPTE process identified the World Federation of Societies of Biological Psychiatry guidelines for the biological treatment of unipolar depression as the starting point for the adaptation process. This document focuses on first-line drug treatment, inadequate response to first-line antidepressant treatment, and duration of such treatment and augmentation strategies within the broader context of electroconvulsive therapy, psychological, and other treatments. For mild depressive episodes, psychological interventions are first-line treatments, and where medication is used, selective serotonin reuptake inhibitors (SSRIs) are first-choice medications (Level B). SSRIs remain the first-choice medications (Level B) for moderate to severe depressive episodes; however, in patients who are partially or non-responding to first-line treatment, switching to venlafaxine appears legitimate (Level C). Antidepressant treatment should be maintained for at least 6months following remission from a first depressive episode but it should be prolonged to 9months in patients with a history of previous episodes and should continue even longer in severe depression or in cases of residual symptomatology until such symptoms have subsided.

More than one-half of a decade of experience with venlafaxine dual serotonin-norepinephrine reuptake inhibitor