Persistent Major Depression Research Articles

Modular-based psychotherapy (MoBa) versus cognitive–behavioural therapy (CBT) for patients with depression, comorbidities and a history of childhood maltreatment: study protocol for a randomised controlled feasibility trial

IntroductionIn depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms, and...

Joy of living through exercise - a qualitative study of clinically referred adolescents’ experiences of moderate to vigorous exercise as treatment for depression

Aim Depression is common and rising in adolescents. Recent meta-analyses indicate a moderate effect of exercise on depression symptoms. Clinically referred adolescents and their experiences of an exercise intervention have rarely been studied. The aim of this study was to describe clinically referred adolescents’ experience of moderate to vigorous exercise as a treatment for depression. Methods A total of 16 clinically referred adolescents with persistent major depression, who had taken part in a 14-week aerobic exercise intervention of moderate to vigorous intensity, were interviewed. Data was analysed by latent qualitative content analysis. Results After taking part in the exercise intervention the adolescents expressed enhanced participation in daily life and joy of living by demonstrating commitment and a sense of empowerment. The categories contained both improved vitality and structure of everyday life as well as improved self-esteem and self-control. Participation in the exercise intervention changed their self-image, relationships, school performance, and family life. The adolescents highlighted that exercising in a group was beneficial, giving security and structure. Conclusions Adolescents with persistent depression experienced several beneficial aspects of participating in an aerobic group exercise of moderate to vigorous intensity.

Aerobic exercise for adolescent outpatients with persistent major depression: Feasibility and acceptability of moderate to vigorous group exercise in a clinically referred sample.

To assess feasibility and acceptability of exercise in clinically referred adolescents with major depression. Outpatients12 to 17 years with mild to moderate persistent depression participated in a supervised, pulse monitored, 14-week aerobic exercise but without control group. Primary outcome was adherence and secondary was clinician-rated Quick Inventory of Depressive Symptomatology - Adolescent (QIDS-A17-C), aerobic capacity, functioning, and well-being. Twenty-one (66%) of 32 eligible adolescents with major depression with disease duration 2.4 (1.1-5.3) years and comorbid ADHD (71%) and anxiety disorders (62%) consented. Estimated maximum heart rate above 70% was achieved for mean 31.6 minutes, indicating that the intensity and duration of the exercise intervention was well received. Fourteen patients (67%) participated throughout the program and attended a median of 29 (81%, range 20-35) supporting satisfaction with the intervention by most patients. QIDS-A17-C score decreased compared to baseline at 15 weeks (p < .001) and further at 1 year (p < .001). Aerobic capacity improved during the intervention but was not maintained, while functioning improved and after 1 year also well-being. This 14 week moderate to vigorous aerobic exercise intervention was feasible and well accepted by most adolescents with persistent depression and extensive comorbidities.

Outcomes and Correlates of Major Depression in 11 Disaster Studies Using Consistent Methods

This study investigated psychosocial functioning and employment status in association with postdisaster major depression and its course in survivors of 11 different disasters in a sample of 808 directly-exposed survivors of 10 disasters and 373 survivors of the 11 September 2001 (9/11), terrorist attacks on New York City’s World Trade Center (total n = 1181). Participants were assessed between 1987 and 2007 with structured diagnostic interviews in a prospective longitudinal design. Consistent research methods allowed merging of the disaster databases for analysis using multivariate modeling. Postdisaster major depression in the study cohort from the 9/11 disaster was more than twice as prevalent as in the other disasters, possibly reflecting the greater psychosocial/interpersonal loss and bereavement experienced by 9/11 disaster survivors. At follow up, employment was associated with remission of postdisaster major depression, non-development of PTSD, and coping via family or friends. Functioning problems were associated with disaster injuries, but not with persistent major depression. This study is unprecedented in its large sample of survivors across the full range of disaster typology studied using consistent methods and full structured interview diagnostic assessment. These findings may help guide future interventions to address postdisaster depression.

The bi-factor structure of the 17-item Hamilton Depression Rating Scale in persistent major depression; dimensional measurement of outcome

The 17-item Hamilton Depression Rating Scale (HDRS17) is used world-wide as an observer-rated measure of depression in randomised controlled trials (RCTs) despite continued uncertainty regarding its factor structure. This study investigated the dimensionality of HDRS17 for patients undergoing treatment in UK mental health settings with moderate to severe persistent major depressive disorder (PMDD). Exploratory Structural Equational Modelling (ESEM) was performed to examine the HDRS17 factor structure for adult PMDD patients with HDRS17 score ≥16. Participants (n = 187) were drawn from a multicentre RCT conducted in UK community mental health settings evaluating the outcomes of a depression service comprising CBT and psychopharmacology within a collaborative care model, against treatment as usual (TAU). The construct stability across a 12-month follow-up was examined through a measurement equivalence/invariance (ME/I) procedure via ESEM. ESEM showed HDRS17 had a bi-factor structure for PMDD patients (baseline mean (sd) HDRS17 22.6 (5.2); 87% PMDD >1 year) with an overall depression factor and two group factors: vegetative-worry and retardation-agitation, further complicated by negative item loading. This bi-factor structure was stable over 12 months follow up. Analysis of the HDRS6 showed it had a unidimensional structure, with positive item loading also stable over 12 months. In this cohort of moderate-severe PMDD the HDRS17 had a bi-factor structure stable across 12 months with negative item loading on domain specific factors, indicating that it may be more appropriate to multidimensional assessment of settled clinical states, with shorter unidimensional subscales such as the HDRS6 used as measures of change.

Adjunctive yoga v. health education for persistent major depression: a randomized controlled trial.

The objective of this study was to determine whether hatha yoga is an efficacious adjunctive intervention for individuals with continued depressive symptoms despite antidepressant treatment. We conducted a randomized controlled trial of weekly yoga classes (n = 63) v. health education classes (Healthy Living Workshop; HLW; n = 59) in individuals with elevated depression symptoms and antidepressant medication use. HLW served as an attention-control group. The intervention period was 10 weeks, with follow-up assessments 3 and 6 months afterwards. The primary outcome was depression symptom severity assessed by blind rater at 10 weeks. Secondary outcomes included depression symptoms over the entire intervention and follow-up periods, social and role functioning, general health perceptions, pain, and physical functioning. At 10 weeks, we did not find a statistically significant difference between groups in depression symptoms (b = -0.82, s.e. = 0.88, p = 0.36). However, over the entire intervention and follow-up period, when controlling for baseline, yoga participants showed lower levels of depression than HLW participants (b = -1.38, s.e. = 0.57, p = 0.02). At 6-month follow-up, 51% of yoga participants demonstrated a response (⩾50% reduction in depression symptoms) compared with 31% of HLW participants (odds ratio = 2.31; p = 0.04). Yoga participants showed significantly better social and role functioning and general health perceptions over time. Although we did not see a difference in depression symptoms at the end of the intervention period, yoga participants showed fewer depression symptoms over the entire follow-up period. Benefits of yoga may accumulate over time.

Rate and Predictors of Persistent Major Depressive Disorder in a Nationally Representative Sample.

This study examined predictors of persistent major depressive disorder over 10years, focusing on the effects of clinical variables, physical health, and social support. Data from the National Survey of Midlife Development in the United States in 1995-1996 and 2004-2006 were analyzed. Logistic regression was used to predict non-recovery from major depression among individuals who met clinical-based criteria for major depressive disorder at baseline. Fifteen percent of the total sample was classified as having major depression in 1995-1996; of these individuals, 37% had major depression in 2004-2006. Baseline variables that were significantly associated with persistent major depression at follow-up were being female, having never married, having two or more chronic medical conditions, experiencing activity limitation, and less contact with family. Therefore, treatment strategies focused on physical health, social support, and mental health needs are necessary to comprehensively address the factors that contribute to persistent major depressive disorder.

The validity and responsiveness of the EQ-5D measure of health-related quality of life in an adolescent population with persistent major depression

BackgroundDespite a preference for economic evaluations to measure outcomes in terms of quality-adjusted life years, generic measures of outcome are rarely used in mental health research involving young people.AimsTo explore the validity and responsiveness of the EQ-5D measure of health-related quality of life in adolescents with major depression.MethodData came from a clinical trial involving adolescents with persistent major depression (n = 199). Construct validity was tested using socio-demographic constructs and baseline clinical outcome scores. To assess convergent validity, correlation between EQ-5D and clinical outcome scores was tested. To assess responsiveness, the mean change in EQ-5D scores of participants categorised as improved versus not improved on clinical outcome measures was tested.ResultsSignificant differences in mean EQ-5D score were found for co-morbidity and three of four severity measures but not gender, age, treatment history or suicide attempts. Mean EQ-5D scores were significantly correlated with all clinical outcome measures, although relationships were moderate or weak. A change in mean EQ-5D score was significantly related to clinical assessments of improvement on all outcome measures.ConclusionsResults provide initial evidence to support the relevance of the EQ-5D in adolescents with major depression, but this evidence is weak. Replication studies are needed to assess the generalisability of these findings.

Socioeconomic disadvantage increases risk of prevalent and persistent depression in later life

Depression is more frequent in socioeconomically disadvantaged than affluent neighbourhoods, but this association may be due to confounding. This study aimed to determine the independent association between socioeconomic disadvantage and depression. We recruited 21,417 older adults via their general practitioners (GPs) and used the Patient Health Questionnaire (PHQ-9) to assess clinically significant depression (PHQ-9≥10) and major depressive symptoms. We divided the Index of Relative Socioeconomic Disadvantage into quintiles. Other measures included age, gender, place of birth, marital status, physical activity, smoking, alcohol use, height and weight, living arrangements, early life adversity, financial strain, number of medical conditions, and education of treating GPs about depression and self-harm behaviour. After 2 years participants completed the PHQ-9 and reported their use of antidepressants and health services. Depression affected 6% and 10% of participants in the least and the most disadvantaged quintiles. The proportion of participants with major depressive symptoms was 2% and 4%. The adjusted odds of depression and major depression were 1.4 (95% confidence interval, 95%CI=1.1-1.6) and 1.8 (95%CI=1.3-2.5) for the most disadvantaged. The adjusted odds of persistent major depression were 2.4 (95%CI=1.3-4.5) for the most disadvantaged group. There was no association between disadvantage and service use. Antidepressant use was greatest in the most disadvantaged groups. The higher prevalence and persistence of depression amongst disadvantaged older adults cannot be easily explained by confounding. Management of depression in disadvantaged areas may need to extend beyond traditional medical and psychological approaches.

Predictors of Major Depression Six Months After Admission for Outpatient Treatment

This study examined the rate and predictors of major depression six months after outpatient mental health admission. Assessments were conducted at admission and three and six months later among 166 participants. Antidepressant treatment adequacy and depression outcomes were assessed at follow-ups. Predictors of major depression at six months included nonremission status at three months (odds ratio [OR]=3.56, p=.003), inadequacy of early pharmacotherapy (OR=2.73, p=.009), worse physical functioning measured by the 36-Item Short-Form Health Survey (OR=.975, p<.001), and being unmarried (OR=2.54, p=.031). The findings support the effects of baseline physical disability, marital status, early treatment adequacy, and early remission on the course of major depression. The identification of individuals who do not receive intensive pharmacotherapy or who have not recovered by three months may provide opportunities for interventions to optimize six-month outcomes and to prevent the development of a persistent depression.

Unmet Needs of Families of Adults With Mental Illness and Preferences Regarding Family Services

Unmet Needs of Families of Adults With Mental Illness and Preferences Regarding Family Services

Recognition of depression in older medical inpatients discharged to ambulatory care settings: a longitudinal study

Objective This study aimed to examine the recognition of depression in older medical inpatients by nonpsychiatric physicians over a 2-year period. Methods A cohort of medical inpatients aged 65 and above was recruited at two university-affiliated hospitals, with oversampling of depressed patients. Participants were assessed with research diagnoses of major or minor depression ( DSM-IV) at admission and at 3, 6 and 12 months. Indicators of recognition during the 12 months before and the 12 months after admission, derived from administrative databases, included the following: depression diagnosis, antidepressant prescription and psychiatric referral. Multiple logistic regression analyses were used to identify factors associated with recognition. Results Among 185 patients with at least one research diagnosis of depression during the study, recognition rates ranged up to 56% during the 12 months before admission among patients with major depression lasting at least 6 months and up to 61% during the 12 months after admission among patients with persistent major depression. In both study periods, a greater number of physician visits and prescription of a psychotropic medication (non-antidepressant) were independently associated with recognition. Conclusions A longitudinal approach to measuring recognition of late-life depression in ambulatory care settings indicates that persistent major depression is more likely to be recognized than previously reported.

Psychological distress in the first year after diagnosis of HIV infection among women in South Africa

Cross-sectional studies on psychological responses associated with an HIV diagnosis are replete, but a paucity of research exists to evaluate the changes and stability of these responses, particularly among black African women. One hundred and five HIV-positive black and coloured women were studied as they reported for follow-up health management at the outpatient clinic for infectious diseases at Tygerberg Hospital in Cape Town, South Africa. They were assessed at baseline and 51 returned for a follow-up interview six months later. Assessments involved use of the Mini-International Neuropsychiatric Interview (MINI), the Carver Brief COPE, and the Sheehan Disability Scale. Negative life events and risk behaviours were also evaluated. Fifty-nine women (56.2%) were diagnosed with at least one psychiatric disorder on the MINI at baseline. The most frequent diagnosis was major depression (38.1%), followed by dysthymic disorder (22.9%). A diagnosis of HIV or AIDS exacerbated the premorbid state of 19% of the women who reported a past history of depression. Twelve women (11.4%) were at risk for suicide, while 19% met criteria for a clinical diagnosis of post-traumatic stress disorder (PTSD) and 6.7% met the diagnosis of generalised anxiety disorders. At follow-up, 26 (51%) were diagnosed with at least a psychiatric disorder. Eleven (21.6%) met the criteria for major depression, while eight (15.7%) had a past history of depression. The number of women with PTSD increased from 19% of the total sample at baseline to 29.4% of those interviewed at follow-up. Conversely, the number with dysthymia dramatically decreased from 24 women (22.9%) at baseline to just one woman at follow-up. The number displaying suicidality also decreased from 12 at baseline to four at follow-up. At both baseline and follow-up, the number and impact of negative life events significantly increased the likelihood of major depression persisting or recurring, but this association was not found for PTSD. These findings indicate that, over time, there is variability in psychiatric morbidity among coloured and black African women living with HIV and that a high number of negative life events may increase the likelihood of persistent major depression in these women.

Recovery From Depression Predicts Lower Health Services Costs

To examine the association between outcome of acute-phase depression treatment and subsequent health services costs. Data from 9 longitudinal studies of patients starting depression treatment were used to examine the relationship between outcome of acute-phase treatment and health services costs over the subsequent 6 months. All studies were 2- to 4-year studies conducted between the years 1991 and 2004. Assessment of diagnosis was done using the Inventory of Depressive Symptoms or the Structured Clinical Interview for DSM-IV. Clinical outcomes were assessed by structured telephone interviews using the Hamilton Rating Scale for Depression or a 20-item depression scale extracted from the Hopkins Symptom Checklist. Costs were assessed using health plan accounting records. Of 1814 patients entering treatment and meeting criteria for major depressive episode, 29% had persistent major depression 3 to 4 months later, 37% were improved but did not meet criteria for remission, and 34% achieved remission of depression. Those with persistent depression had higher baseline depression scores and higher health services costs before beginning treatment. After adjustment for baseline differences, mean health services costs over the 6 months following acute-phase treatment were 2012 dollars (95% CI = 1832 dollars to 2210 dollars) for those achieving remission, 2571 dollars (95% CI = 2350 dollars to 2812 dollars) for those improved but not remitted, and 3094 dollars(95% CI = 2802 dollars to 3416 dollars) for those with persistent major depression. Average costs for depression treatment (antidepressant prescriptions, outpatient visits, and mental health inpatient care) ranged from 429 dollars in the full remission group to 585 dollars in the persistent depression group. Among patients treated for depression in community practice, only one third reached full remission after acute-phase treatment. Compared with persistent depression, remission is associated with significantly lower subsequent utilization and costs across the full range of mental health and general medical services.

Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care. This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart. The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (-1.3 versus -0.9) and equivalent at 6 months (-1.3 versus -1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale. Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research.

A double-blind, placebo-controlled study of antidepressant augementation with mirtazapine

Background: A previous pilot study of open-label mirtazapine augmentation conducted by the authors in 20 depressed patients yielded a 55% response rate at week 4. A double-blind controlled trial was undertaken to further elucidate the efficacy of this intervention. Methods: 26 adult outpatients with persistent major depression despite adequate antidepressant monotherapy were randomized to receive 4 weeks of mirtazapine or placebo augmentation. Mirtazapine was begun at 15 mg at bedtime, with possible titration to 30 mg at bedtime per physician’s discretion after week 1. Results: Categorical positive response rate at end point was 64% for active drug and 20% for placebo. Remission rates were 45.4% and 13.3% for active drug and placebo groups, respectively, Mirtazapine demonstrated statistically significant superiority to placebo on most major outcome measures, and was associated with improvement in overall functioning and quality of life. There were no significant group differences with regard to emergent side effects, weight change, or serum concentrations of primary antidepressants. Conclusions: Mirtazapine appears safe and effective for short-term antidepressant augmentation.

Adrenal steroid secretion and major depression in 8- to 16-year-olds, III. Influence of cortisol/DHEA ratio at presentation on subsequent rates of disappointing life events and persistent major depression.

An investigation of the association between diurnal changes in cortisol and DHEA levels, or in the cortisol/DHEA ratio at five different time points at presentation, and the occurrence of undesirable life events (losses, dangers to self and others, disappointments) during follow-up, and the outcome of major depression at 36 weeks were investigated. Psychosocial and endocrine assessment of a consecutive cohort (N = 68) of 8- to 16-year-old subjects with first episode major depression reassessed 12 months after presentation using a repeat measures design. Higher cortisol/DHEA ratios at 20.00 or 24.00 h predicted persistent major depression. Basal levels of either hormone alone or cortisol/DHEA ratios at the other three time points (08.00, 12.00 or 16.00 h) did not. High cortisol/DHEA ratios (i.e. values greater than the 60th percentile) at both evening points (20.00 and 24.00 h) also predicted the occurrence of subsequent disappointing life events but no other category of undesirable event. Both high evening cortisol/DHEA ratio at 20.00 h and one or more severely disappointing life events between presentation and follow-up predicted persistent major depression: 86% of subjects with both of these factors were still depressed at 36 weeks whereas 81% with neither factor were not. The finding that it is depressed subjects with high cortisol/DHEA ratios at presentation who are specifically at risk for subsequent disappointing life events suggests a putative role for these adrenal steroids in abnormal cognitive or emotional processes associated with disturbed interpersonal behaviour.

Depression in attention deficit hyperactivity disorder (ADHD) children: “True” depression or demoralization?

Background: The purpose of this study was to further evaluate the nature of the association between major depression (MD) and attention deficit hyperactivity disorder (ADHD) by examining predictors of persistence of MD attending to issues of familiality, adversity and comorbidity. Methods: Four years of follow-up of 76 depressed ADHD children were analyzed using multivariate regression to determine predictors of persistent MD. Results: Bipolar disorder and higher indices of interpersonal problems predicted MD persistence. In contrast, school difficulty and ADHD-associated measures of severity were not associated with persistent MD. Remission from ADHD was also not statistically significantly associated with remission from MD. Conclusions: ADHD and MD had independent and distinct courses, indicating that ADHD-associated MD reflects a depressive disorder and not merely demoralization. Limitations: This study may have reduced power due to stratification of our group of ADHD boys with persistent and remitting MD.

Depression in medically ill hospitalized older adults: prevalence, characteristics, and course of symptoms according to six diagnostic schemes.

The purpose of this study was to examine and compare rates of depression, correlates, and course of symptoms in medically ill hospitalized elders through use of six diagnostic schemes (inclusive, etiologic, exclusive-inclusive, exclusive-etiologic, substitutive-inclusive, and substitutive-etiologic). A consecutive series of 460 cognitively unimpaired patients aged 60 or over who were admitted to the medical inpatient services of Duke Hospital underwent a structured psychiatric evaluation administered by a psychiatrist. Patients with depression were contacted by telephone at 12-week intervals after discharge to assess weekly change in depressive symptoms (median follow-up time = 47 weeks). The prevalence of major depression varied from 10% to 21% depending on diagnostic scheme; similarly, minor depression varied from 14% to 25%. Diagnostic strategy made little difference in known psychological and health characteristics of patients with depression (predictive validity) or severity of depressive symptoms (convergent validity). The diagnostic strategy that best distinguished a severe and persistent major depression was the exclusive-etiologic approach; however, this strategy missed 49% of patients with major depression identified by the inclusive approach, almost 60% of whom continued to experience persistent symptoms of depression many weeks after discharge. Diagnostic strategy affects rates of major and minor depression, with about a twofold difference between the extremes. There is little reason, however, to choose one diagnostic scheme over another in all cases. Diagnostic strategy should be chosen on the basis of the specific goals and purposes of the examiner. While the exclusive-etiologic approach identifies the most severe and persistent depressions, the inclusive approach is the most sensitive and reliable approach and is an intermediate predictor of persistent depression.

Short-Term Outcome of Major Depression: II. Life Events, Family Dysfunction, and Friendship Difficulties as Predictors of Persistent Disorder

To determine whether there is a pattern of social characteristics that specifically predicts persistent major depression at 36 weeks follow-up. Sixty-eight consecutive cases with a first-episode DSM-III-R diagnosis of major depression completed a life events and friendship difficulties interview at presentation and again at 36 weeks. Four factors were associated with persistent psychiatric disorder in general: lack of a maternal confiding relationship with current partner, family dysfunction and poor friendships at presentation, and severely disappointing events between presentation and follow-up. There was no association between these adverse experiences. No combination of long-term or recent life events or difficulties was, however, specifically associated with persistent depression. Nonsocial factors may need to be taken into account to specifically explain the phenotypic persistence of major depressive disorder in first-episode nonrecovered cases within a year of presentation. Psychosocial interventions with first-degree relatives and current close friendships should be considered as a part of the treatment strategy for first-episode major depression.