Depressed Outpatients Research Articles

A therapeutic application of the experience sampling method in the treatment of depression: a randomized controlled trial

In depression, the ability to experience daily life positive affect predicts recovery and reduces relapse rates. Interventions based on the experience sampling method (ESM-I) are ideally suited to provide insight in personal, contextualized patterns of positive affect. The aim of this study was to examine whether add-on ESM-derived feedback on personalized patterns of positive affect is feasible and useful to patients, and results in a reduction of depressive symptomatology. Depressed outpatients (n=102) receiving pharmacological treatment participated in a randomized controlled trial with three arms: an experimental group receiving add-on ESM-derived feedback, a pseudo-experimental group participating in ESM but receiving no feedback, and a control group. The experimental group participated in an ESM procedure (three days per week over a 6-week period) using a palmtop. This group received weekly standardized feedback on personalized patterns of positive affect. Hamilton Depression Rating Scale - 17 (HDRS) and Inventory of Depressive Symptoms (IDS) scores were obtained before and after the intervention. During a 6-month follow-up period, five HDRS and IDS assessments were completed. Add-on ESM-derived feedback resulted in a significant and clinically relevant stronger decrease in HDRS score relative to the control group (p<0.01; -5.5 point reduction in HDRS at 6 months). Compared to the pseudo-experimental group, a clinically relevant decrease in HDRS score was apparent at 6 months (B=-3.6, p=0.053). Self-reported depressive complaints (IDS) yielded the same pattern over time. The use of ESM-I was deemed acceptable and the provided feedback easy to understand. Patients attempted to apply suggestions from ESM-derived feedback to daily life. These data suggest that the efficacy of traditional passive pharmacological approach to treatment of major depression can be enhanced by using person-tailored daily life information regarding positive affect.

Treatment-resistant depression: state of the art. Part I. Nosography and clinic

This work would give an overall vision of the actual knowledge about nosography and clinic of treatment-resistant depression. A PubMed, PsychInfo, Google Scolar search was done using the key words "resistant depression", "STAR*D", "bipolar depression", "staging". Have been selected exclusively works in English, French and Italian languages. Treatment-resistant depression is one of the most important problem in public health. Nevertheless a general consensus about its definition and staging does not exist at now. Principal risk factors and associated comorbidities are well known including the association with bipolar spectrum; anyway the disease particularly common among depressed outpatients is still very disabling, responsible of an often chronic course, with numerous relapses and high risk of suicide. The future investigations, once improved procedures for differential diagnosis and subtyping of clinical depression, should be directed to the search of a shared definition of treatment resistance and the development of specific therapeutic protocols.

Clinical Features of Night Eating Syndrome among Depressed Patients

The aim of this study was to investigate the frequency and clinical features of night eating syndrome (NES) in a sample of patients with depression. The study sample consisted of 155 depressed outpatients. Socio-demographic Form, Beck Depression Inventory, Beck Anxiety Inventory, Maudsley Obsessive-Compulsive Inventory, Pittsburgh Sleep Quality Index (PSQI) and Night Eating Questionnaire were utilised for data collection. Night eating syndrome was identified in 21.3% of the patients. Comparisons between NES and non-NES patients revealed significant differences in BMI, smoking status, Beck Depression Inventory, Beck Anxiety Inventory, rumination and PSQI sub-scores for sleep quality, latency, disturbances and daytime dysfunction. In our sample, the predictors of NES were BMI, smoking and the subject's score on the PSQI sleep disturbances subscale. Night eating syndrome is negatively associated with sleep, severity of anxiety and depression. Our findings suggest that there is a complex relation between NES and depression, and it is recommended that depressed patients be evaluated for NES.

EPA-1376 – Interpersonal psychotherapy in the treatment of mental illness in the vulnerable economic scenario nowadays: an exploratory study with depressed outpatients

Introduction Portugal is a country with severe economic difficulties for the last 2 years. Considering the volatile and vulnerable economic social system today, in Portugal, the number of jobs decreased, unemployment increased and, as a consequence, mental illnesses as well. Because of it, and, the request for quicker treatments of mental health by the population are increasing significantly. Objective Our objective is to evidence in Portugal one of the very first IPT researches as an advisable treatment of acute major depressive disorder, mainly in the current economic scenario, contributing to evidence an effective way to combat mental illness in Portugal. Methods The ongoing longitudinal study consist of adult outpatients (n=50), diagnosed with acute major depressive episode. The intensity of depression was measured is sessions 1, 6 and 10, with the Center for Epidemiological Studies Depression Rating Scale (CES-D). The procedure is focused in one of four IPT problem areas (role transitions, disputes, grief and loss, and difficulties initiating or sustaining relationships). Results The first results show significant trend to identify the Disputes as the main problem-area. The intensity of the depression is significant lower along sessions with same patients. In 8th session, there is a significant decrease of the depressive symptomatology and the patient is more functional and adapted. Conclusions Our research evidences the vulnerability to social context amidst the Portuguese economic crisis to depression, as well it evidences the effectiveness of IPT as a brief psychotherapy that responds to the current needs of a population with growing economic difficulties.

EPA-0762 – Beyond depressive symptoms, how agomelatine modifies emotional reactivity, cognitive speed, motivation, psychomotor function and sensory perception?

Baseline values and early changes of emotional reactivity, cognitive speed, psychomotor function, motivation and sensory perception have been poorly studied in unipolar depression, although they could help to characterize different dimensions harder to capture by clinicians, give new insights on how patients are improved, and offer new markers depicting how early changes testify later treatment response. 1565 adult outpatients with MDD receiving agomelatine completed QIDS-C, CGI and MATHYS scales at inclusion, W2 and W6. The MATHYS includes 20-item self-rated visual analogue scales (from inhibition -0- to activation -10- with -5- representing the usual state) leading to five a priori dimensions (emotional reactivity, cognitive speed, psychomotor function, motivation and sensory perception). All dimensions increased from inclusion to W2 and from W2 to W6 (p<10 −3 ). Roughly, improvement was 2-point (out of 10) for motivation, 1.5 for psychomotor function and 0.5 for other dimensions. Motivation: (1) had a trend as being more severe at inclusion in later non-responders (t=1.25, df=1563, p=0.10) (2) displayed the highest difference at W2 in later responders versus non-responders (t=7.98, df=1563, p<10–6) (3) correlated the highest with QIDS-C improvement (r=0.22, df=1563, p<10–6) (4) best predicted at W2 later treatment response as per the highest area under the ROC curve (AUC=0.606, 95%CI[0.588–0.643], p<0.001). Motivation had the earliest capacity to be improved, the best predictive value for treatment response and the largest global margin of progress in depressed outpatients. Assessing self-reported motivation in MDD could offer an interesting paradigm shift while assessing linear changes of depressive symptoms.

EPA-0806 - Effectiveness of agomelatine in outpatient depressives : Preliminary results

35 outpatients with DSM-IV major depression under agomelatine treatment (25 or 50 mgs/day) were followed up for a minimum of two months. Two groups were identified, one under monotherapy with agomelatine (N=20)and the other (N=15) under combined treatment with another antidepressant or mood stabilizer. Hamilton Depression Rating Scale was administered at first fortnightly and then every month for at least two months. There was a mean reduction in HAM-D at endpoint of 9,7 units on both groups. A greater reduction (11,1 units) was found in the group under 50 mgs/day but he different was marginally statistically significant. Another interesting preliminary finding was that a better outcome was observed in monotherapy patients (- 11 units) in comparison with combined therapy patients (-8,4), a non-significant finding. The most common reported adverse event was headache (14,6%). Also, polytherapy was combined with an older patient age. Other interesting clinical observations are discussed in this ongoing open label study.

Major depression in high-risk obstetric inpatients and outpatients

Major depression in high-risk obstetric inpatients and outpatients

A brief cognitive-behavioural group therapy programme for the treatment of depression in adolescent outpatients: a pilot study.

BackgroundThe goal of this pilot study was to examine the feasibility and clinical outcomes of a brief (6-session) group therapy programme in adolescent outpatients with depression. The programme had previously been assessed in in-patients, with positive results.MethodsA total of 15 outpatients aged 13 to 18 years took part in the programme between October 2010 and May 2011, in 3 separate groups of 4–6 participants each. The outcomes measured were feasibility of the programme, as assessed by attendance rate, user feedback, fidelity of implementation, and response to treatment, as assessed by pre- and post-intervention measurement of depressive symptoms, quality of life, and suicidal ideation.ResultsThe programme demonstrated good feasibility, with a mean attendance rate of 5.33 out of 6 sessions, a mean rating by participants on overall satisfaction with the programme of 7.21 out of 10 (SD = 1.89), and a 93% concurrence between the contents of the sessions and the contents of the treatment manual. Compared to baseline scores, depressive symptoms at follow-up test were significantly reduced, as assessed by the Children’s Depression Rating Scale Revised (F(1, 12) = 11.76, p < .01) and the Beck Depression Inventory Revision (F(1, 32) = 11.19, p < .01); quality of life improved, as assessed by the Inventory of Quality of Life (F(1, 31) = 5.27, p < .05); and suicidal ideation was reduced. No significant changes were seen on the measures of the Parent Rating Scale for Depression and the Clinical Global Impression scale.ConclusionsBased on the results of this pilot study, it is feasible to further assess this brief outpatient treatment programme in a randomized controlled trial without further modifications.

EPA-1756 - EEG activity in the gamma band and late positive potential (LPP) during processing attachment-related stimuli

Patients with Major Depression (MD) experience increased negative affect, associated with dysfunction in the regulation of emotions, cognitive control and processing of self-referential information, suggesting prefrontal involvement. Gamma band activity is known to play a role in integrating cognitive processes whereas late positive potentials (LPP) are crucial for emotion regulation. Here, we investigate neural correlates during elaboration of attachment-relevant personalized stimuli in MD. Identifying neural correlates of MD during exposure to attachment-relevant stimuli with EEG. To find out whether an increase in the gamma band and LPP may be related to the elaboration of attachment-relevant personalized stimuli in MD. 20 depressed (DSM-IV) unmedicated outpatients and healthy controls (N = 20) were presented with a validated set of seven standardised attachment-related scenes. Each picture stimulus was accompanied by three neutral sentences and three personal attachment relevant keysentences derived form a previously conducted attachment interview. EEG recording was performed with 32 electrodes. Evoked gamma activity was characterized by a Morlet wavelet transformation using the software Brain Vision Analyzer 2.0. We computed LPP for the time slot 500–1000 ms. Patients showed higher levels of gamma activity and late positive potentials than control participants in fronto-central electrode sites that have been previously associated with emotion regulation and cognitive functions. The present study offers evidence that EEG gamma activity reflects important indicators of processing personal affective stimuli in MD compared to healthy individuals. The involvement of the medial prefrontal cortex may also relate to the self-focused functioning that characterizes depressed individuals.

EPA-0142 – Neural changes in depressed patients during psychodynamic psychotherapy: An fMRI Study

Neuroimaging studies of depression have demonstrated treatment-specific changes involving the limbic system and regulatory regions in the prefrontal cortex. While these studies have examined the effect of short-term, interpersonal or cognitive-behavioural psychotherapy, the effect of long-term, psychodynamic intervention has never been assessed. Here, we investigated recurrently depressed ( DSM-IV ) unmedicated outpatients ( N =16) and control participants matched for sex, age, and education ( N =17) before and after 15 months of psychodynamic psychotherapy. Participants were scanned at two time points, during which presentations of attachment-related scenes with neutral descriptions alternated with descriptions containing personal core sentences previously extracted from an attachment interview. Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy. Signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy.

EPA-0017 – Remission decreased outpatient visit counts in depressed primary care patients treated with collaborative care management or usual care

Introduction Depression symptoms contribute to significant morbidity and health care utilization. Healthcare reform should consider improvements in clinical outcomes as well as decreased overall utilization as mechanisms to control health care costs. Objectives/Aims The aim of this study was to determine the impact of remission on outpatient clinical visits by depressed primary care patients in collaborative care management (CCM) or usual care (UC). The hypothesis was that depressed patients with worse outcomes at six months would have increased outpatient visit counts, regardless of treatment type. Methods The study was a retrospective, chart review analysis of 1,733 patients with six month follow-up data. The data set included baseline data (demographic information, diagnosis, medical comorbidity, prior outpatient visit counts and depression severity) and six month follow up data (PHQ-9 scores and number of outpatient visits utilized). Results Multiple logistic regression demonstrated that remission at six months was an independent predictor of outpatient visit outlier status (>8 visits) (OR 0.609 CI 0.460-0.805, p Conclusions In primary care patients treated for depression, successful treatment to remission at six months decreased the likelihood of the patient having more than 8 visits during the six months after diagnosis. This holds true even when controlling for the individual patient's prior outpatient visit counts, health care comorbidities and enrollment into CCM vs. UC.

EPA-0483 – Who expects what influences what they get: the prediction of therapy outcome by various types of expectancies and the influence of therapist factors

Patients’expectancies have long been considered to contribute to treatment outcome. Whereas research has concentrated on different types of expectancies in predicting outcome, it has not examined their interactive contribution, therapist factors, nor the development of expectancies over time. Therefore, the present study aims to investigate the independent as well as the interactive contributions of outcome expectancies (OE) and negative mood regulation expectancies (NMRE) to outcome. One hundred and fourty depressed outpatients in cognitive-behavior psychotherapy completed measures of OE and NMRE at pretreatment and midtreatment, as well as outcome measures at midtreatment and posttreatment. Patients’ OE were assessed using the Patients’ Therapy Expectation and Evaluation Questionnaire (PATHEV; Schulte, 2005), and the short form of the Negative Mood Regulation Scale (NMR; Backenstrass et al., 2010). Outcome was measured using the German version of the Beck Depression Inventory – II (BDI-II; Hautzinger, Keller, & Kühner, 2006), and the Inventory of Depressive Symptomatology - Clinician Rated 30-item version (IDS-C; Rush, Carmody, & Reimitz, 2000). We will perform three-level multiple longitudinal hierarchical analysis, with different assessment time points as the first level, nested in patients (second level), which are nested in therapists (third level), controlling for comorbidities. We expect OE and NMRE to change significantly during therapy, and these changes to be related to outcome, both at midtreatment and posttreatment. We also expect to find a significant interaction between OE and NMRE in predicting outcome, as well as a significant influence of therapists on patients's expectancies. Theoretical and clinical implications of the results will be discussed.

Speaking a More Consistent Language When Discussing Severe Depression

We recently found marked disparities between 3 self-report scales that assess the DSM-IV criteria for major depressive disorder in the percentage of depressed outpatients considered to have severe depression. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to calibrate the measures against a clinician-rated criterion standard and to establish a cutoff point on each scale that identifies a similar prevalence of severe depression and increases the level of agreement between the scales in identifying severe depression. 353 depressed outpatients (DSM-IV) completed the Clinically Useful Depression Outcome Scale, Quick Inventory of Depressive Symptomatology, and Patient Health Questionnaire from June 2010 to January 2013. The patients were also rated on the 17-item Hamilton Depression Rating Scale (HDRS). The goal of the analyses was to identify the cutoff point on each of the self-report scales that would identify a prevalence of severe depression similar to that identified by the HDRS (defined as a score of 25 and above). On the basis of the scale developers' recommended cutoffs, the prevalence of severe depression varied greatly (range, 15.3%-67.4%), and the level of agreement between the pairs of scales was low. After calibration, the self-report scales identified a similar percentage of patients as severely depressed (range, 22.2%-26.5%), and the level of agreement between the scales in identifying severe depression increased. If clinicians are to follow treatment guidelines' recommendations to base initial treatment selection, in part, on depression severity, then it is important to have a consistent method of determining depression severity. The present calibration study of 3 self-report depression questionnaires identified cutoff scores that resulted in similar prevalence rates of severe depression and increased the level of agreement between the scales.

Anhedonia and Pain Avoidance in the Suicidal Mind: Behavioral Evidence for Motivational Manifestations of Suicidal Ideation in Patients With Major Depressive Disorder

Psychological pain may be helpful in conceptualizing suicidal behavior, in that high motivation to avoid pain combined with painful feelings may contribute to an increased risk of suicide. However, no experimental study has tested this hypothesis. The aim of the present study is to provide empirical evidence for the relationship between anhedonia, pain avoidance motivation, and suicidal ideation. The sample comprised 40 depressed outpatients and 20 healthy control subjects. All participants completed the Beck Scale for Suicide Ideation (BSS), Beck Depression Inventory, Psychache Scale, Three-Dimensional Psychological Pain Scale, the monetary incentive delay (MID), and affective incentive delay (AID) tasks. Based on BSS scores, clinical participants were divided into high suicidal ideation (HSI) and low suicidal ideation (LSI) groups. In the AID task, the HSI group had longer response times (RTs) under the reward condition than those under the punishment condition (p = .002). The LSI and control groups had shorter RTs under the reward condition compared with those under the neural condition (p <.001 and p = .008, respectively). The LSI group also had shorter RTs under the reward condition than under the punishment condition (p = .003). Pain arousal (r = -.33, p <.01) and BSS scores were significantly negatively correlated with differences in RTs between neutral and reward conditions. Pain avoidance (r = .35, p <.01) and BSS scores were positively correlated with differences in RTs between neutral and punishment conditions. The AID task was more sensitive than the MID task for the detection of participants' motivation in approaching hedonic experiences and avoiding pain. A suicidal mindset is manifested as decreased motivation to experience hedonia and increased motivation to avoid pain, which could be strong predictors of suicidal behavior.

Depression und Gedächtnis: Gedächtnisleistungen im Vergleich zwischen Depressiven und Gesunden

This study examines whether patients suffering from a major depression episode or recurrent depression reveal impairments in different memory components compared to healthy controls. Memory functions are examined and compared by assessing the examinees' performances on free recall and recognition tasks. Performances of 200 depressed inpatients and outpatients as well as 200 healthy controls on memory tasks were assessed using a psychometric test battery. Data was evaluated by analyzing the differences of mean values and the heterogeneity of relevant effect sizes. Depressed patients showed lower performances on all episodic memory tasks compared to healthy controls. The size of deficits turned out to vary depending on the type of affective disorder and the type of memory task.

Psychological coping in depressed outpatients: Association with cortisol response to the combined dexamethasone/CRH test

BackgroundDepression is associated with dysfunctional coping styles and dysregulated hypothalamic–pituitary–adrenal (HPA) axis function. Studies have shown that maladaptive coping strategies relate to abnormal HPA axis function; however, such a relationship has been under-studied in patients with depression. We aimed to examine whether dysfunctional coping styles in depression would be associated with abnormal cortisol reactivity. MethodsSeventy-four outpatients with major depressive disorder and 133 age- and sex-matched healthy individuals were recruited. Coping was assessed by the Ways of Coping Checklist. Psychological distress was assessed by the Hopkins Symptom Checklist. Cortisol reactivity was measured by the combined dexamethasone/corticotropin-releasing hormone test. ResultsCompared to healthy individuals, depressed patients demonstrated significantly less use of problem-solving, positive reappraisal and social support coping styles and more use of self-blame and wishful thinking styles. Such a pattern of coping styles was significantly associated with patients' greater distress. Partial correlation analysis in patients, controlling for age and sex, revealed a significant correlation between more use of escape–avoidance coping and lower levels of reactive cortisol measures. A stepwise multiple regression analysis predicting cortisol reactivity from age, sex, distress, symptom severity and coping styles revealed that escape–avoidance coping was a significant predictor. LimitationsThe neuroendocrine challenge test was administered only once, based on a simple test protocol. ConclusionsMore use of escape–avoidance coping in depressed patients was associated with less cortisol reactivity. Our findings shed light on the heterogeneity of depression in terms of low and high levels of avoidance associated with exaggerated and blunted HPA axis reactivity, respectively.

Reliability and validity of a Chinese version of the HADS for screening depression and anxiety in psycho-cardiological outpatients

AimThe Hospital Anxiety and Depression Scale (HADS) has been used widely with cardiovascular patients. This study aims to examine the reliability and validity of a Chinese version of HADS among psycho-cardiological outpatients. MethodsOne hundred psycho-cardiological outpatients were asked to complete the Chinese version of HADS and were then interviewed according to the Mini International Neuropsychiatric Interview, Version 5 (MINI). ResultsAccording to the MINI, 38 outpatients were diagnosed with major depression and 15 outpatients were diagnosed with an anxiety disorder. Compared with the MINI diagnoses, the optimum cutoff value of the anxiety subscale (HADS-A) was six (6) with a sensitivity of 81.6%, specificity of 75.8%, positive predictive value (PPV) of 54.0% and negative predictive value (NPV) of 91.9%; at the optimum cutoff value of nine (9), the depression subscale (HADS-D) had a sensitivity of 80.0%, specificity of 92.9%, PPV of 52.2% and NPV of 96.1%. The Cronbach's alpha coefficients of the HADS-A and HADS-D subscales were 0.753 and 0.764, respectively. The areas under the ROC curves of the HADS-A and the HADS-D subscales, as compared to MINI diagnoses of anxiety and depression, were 0.81 (SE=0.05, 95%CI: [0.73, 0.90]) and 0.86 (SE=0.05, 95%CI: [0.77, 0.94]), respectively. ConclusionsThe HADS was found to be a reliable measurement tool for excluding depression and anxiety in psycho-cardiological outpatients.

Depressed adolescents as young adults – Predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up

BackgroundClinically derived follow-up studies examining the predictors of suicide attempts (SA) and non-suicidal self-injury (NSSI) among adolescents are scarce. The aims were to study SA and NSSI as predictors of future NSSI and SA, and to study the role of other risk and protective factors, especially alcohol use, and perceived social support from family and peers during a 1-year follow-up and between the 1-year and 8-year follow-ups among consecutively referred depressed adolescent outpatients. MethodsThe Adolescent Depression Study (ADS) is a longitudinal study of depressed adolescent outpatients (mean age at baseline 16.5 years, 81.8% females). The subjects of the present study (n=139, 63.8% of the original study population) were assessed at baseline, at 1-year and 8-year follow-ups using semi-structured diagnostic interviews (K-SADS-PL) for DSM-IV diagnoses, and structured self-report scales for clinical risk factors. ResultsIn multivariate comparisons, SAs were predicted both in the 1-year follow-up and in the period between the 1- and 8-year follow-ups by alcohol use and low perceived peer support. NSSI in the 1-year of follow-up was predicted by baseline NSSI, younger age and alcohol use, whereas the only significant predictor for NSSI between the 1- and 8-year follow-ups was NSSI. LimitationsA large majority of the sample were females, limiting the possibility to analyze gender differences. ConclusionsAmong depressed outpatients NSSI is a strong predictor of suicidal behavior, and other factors beyond depression, such as alcohol use and availability of social support, must also be addressed to prevent the recurrence of suicidal behavior.

Ketamine for Treatment-Resistant Depression: Ready or Not for Clinical Use?

(Reprinted with permission from the American Journal of Psychiatry 2013; 170(10):1079–1081)

Depression in young adult psychiatric outpatients: delimiting early onset

The aim of this study was to examine differences in childhood, adolescent and adult onset of depression. Young psychiatric outpatients (n = 156) diagnosed with a lifetime depressive episode were divided into three groups according to age of onset of their first depressive episode: childhood (≤12 years, n = 21), adolescent (13-17 years, n = 58) and early adult onset (18-25 years, n = 77). Participants were assessed by diagnostic interviews and by questionnaires measuring previous life events and childhood developmental delays. Clinical characteristics and various risk factors were compared between groups. This clinical sample was dominated by women, with onset of their first depressive episode occurring during adolescence. Childhood onset was related to an increased number of depressive episodes, higher prevalence of personality disorders, more current social problems and more reported development delays during childhood regarding literacy learning, social skills and memory. They also reported more separation anxiety symptoms and neglect during childhood and more experiences of teenage pregnancies and abortions. Childhood onset of depression is associated with more severe symptoms, more psychosocial risk factors and childhood developmental delays. Because all onset groups shared many features, the results are inconclusive if there are distinct subgroups according to age of onset.