Primary Depression Research Articles

Pharmacotherapy of mood disorders in epilepsy: The role of newer psychotropic drugs

Depression in patients with epilepsy (PWE) is a relatively common comorbidity that has a significant negative impact on their quality of life. Therefore, recognition and management of a comorbid depressive disorder is paramount to achieve successful comprehensive treatment in PWE. Depression in epilepsy may mimic primary depressive disorders, but in a significant percentage of depressed PWE, the clinical semiology has an atypical presentation and fails to meed any of the diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Despite the relatively high prevalence of depression in epilepsy and its frequent atypical presentation, there has been only one controlled study (in 1979) to establish the safety and efficacy of antidepressant drugs in PWE. Accordingly, clinicians must rely on data from studies of pharmacotherapy of primary depression. These data are adequate to guide the clinician in the basic principles of pharmacotherapy of depression in PWE. Many questions are yet to be answered, including: 1) are the expectations of symptom remission to pharmacotherapy in PWE different in typical and atypical forms of depression, and do they differ from those of patients with primary depression? and 2) are the doses of antidepressant drugs necessary to yield symptom remission different between PWE and those patients with primary mood disorders?

Psychological techniques in the management of pain

Pain is experienced as a threat to a person's physical and emotional integrity, the more so when it is prolonged and unexplained. Often the fear patients have of doing anything that might worsen the pain or presumed damage is taken as a lack of motivation. For the clinician, there is a dilemma about how far to pursue investigation and attempts at treatment before concluding that the pain is persistent. Careful assessment of pain, of the problems it causes for the patient, and of the patient's thoughts about it provide valuable information for the diagnostician and convey to patients that their difficulties are taken seriously. This article provides simple pain scales. Assessment of mood is also important because the combination of unhappiness and somatic symptoms does not necessarily indicate primary clinical depression. The doctor is in a good position to help the person with pain to understand what is and what is not wrong, to identify suitable targets for functional improvement and to engage the patient in efforts towards recovery or rehabilitation. Pain management techniques, applicable in combination with medical and physical treatments, or when these have been exhausted, are described.

Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis

Although potentially costly, enhancing primary care depression management on an ongoing basis results in substantial long-term treatment effectiveness. The purpose of this article is to compare the cost-effectiveness of this approach with that of usual care. The study was conducted in 12 community primary care practices randomized to enhanced or usual care after stratification by baseline practice patterns. Practices assigned to enhanced care encouraged depressed patients to engage in active treatment, using practice nurses to provide regularly scheduled care management during the course of 24 months. We analyze outcomes for 211 adults (73.4% of potential eligible patients) beginning a new treatment episode for major depression determined by previsit screening. Outcomes included blinded estimates of days free of depression impairment as well as health care costs for 2 years. Enhanced care significantly increased the number of days free of depression impairment for 2 years when compared with usual care (647.6 days vs 588.2 days, P <.01). The incremental cost-effectiveness ratio for enhanced care ranged from 9,592 dollars to 14,306 dollars per quality-adjusted life-year (QALY). The number of incremental days free of depression impairment increased between the first year and the second year (23.0 vs 36.4, respectively, P <.001) while incremental health plan costs decreased significantly (568 dollars vs -12 dollars, P <.001). Enhancing primary care depression management on an ongoing basis should be considered for adoption by policy and health plan leaders.

The Course of Depression in Elderly Patients

Objective: Studies on the course of major depressive disorder (MDD) among elderly persons are limited to short periods of follow-up, seldom provide comparisons with younger cohorts, and raise other methodological concerns. Methods: Utilizing 15 years of prospective data from the NIMH Collaborative Depression Study, the authors examined the index episode of MDD and the time until first observed recurrence in those who recovered for subjects in four age-groups defined by age at intake: 17–30, 31–50, 51–64, and 65–79 years. Assessments were conducted every 6 months for 5 years and annually thereafter. Survival analysis examined time until recovery and time to first recurrence. Results: Median time-to-recovery was similar for the four groups. Median time-to-first recurrence was significantly shorter for oldest versus the 51–64-year-old group but not the two other groups. The oldest age-group was distinguished from the younger groups by being more likely to be divorced/widowed/separated, to have primary depression, and to have a history of medical illness, particularly cardiovascular disease or cancer. There was no difference in the generally low levels of pharmacotherapy prescribed during the index episode or the subsequent well interval. Conclusions: Elderly patients with MDD may have a greater risk of recurrence than younger individuals. Low levels of treatment characterize the somatic treatment in all the study subjects, regardless of age-group.

Depression In Primary Care: Bringing Behavioral Health Care Into The Mainstream

The Robert Wood Johnson Foundation's national program, Depression in Primary Care: Linking Clinical and Systems Strategies, funds three related components to stimulate innovation in primary depression care. The incentives, value, and leadership components evaluate and implement strategies for financing and sustaining use of clinical best practices despite barriers created by economic and organizational structures that fragment behavioral and general health care. A challenge for policymakers is how to link depression care with the management of other chronic conditions, so that they are integrated into the quality improvement agenda of purchasers, payers, and providers without becoming submerged in health care's mainstream.

The Effect of Improving Primary Care Depression Management on Employee Absenteeism and Productivity

To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years. Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening. Practices were stratified by depression treatment patterns before randomization to enhanced or usual care. After delivering brief training, enhanced care clinicians provided improved depression management over 24 months. The research team evaluated productivity and absenteeism at baseline, 6, 12, 18, and 24 months in 326 patients who reported full-or part-time work at one or more completed waves. Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years. Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over 2 years at an estimated annual value of US 1982 dollars per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over 2 years at an estimated annual value of US 619 dollars per depressed full-time equivalent. This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees.

Suicide in severe depression related to treatment

The objective of the present study was to assess the association between depressive characteristics and completed suicide despite adequate antidepressant therapy in severe depression and to investigate the frequency of lethal antidepressant overdoses. A record evaluation of 98 suicide victims with a primary severe depression had been performed. These had been admitted to the Department of Psychiatry, Lund University Hospital between 1956 and 1969 and followed up to 1998. Psychomotor retardation was related to completed suicide after ECT. The estimated frequency of lethal intoxication with antidepressants was low: 3% of the suicides.

Mental and Behavioral Dysfunction in Movement Disorders

Mental and Behavioral Dysfunction in Movement Disorders

Comorbid major depression and panic disorder: significance of temporal sequencing to familial transmission

Background: Panic disorder (PD) and major depression frequently coexist but the nature of the relationship is controversial. Our aim was to determine if the risk for depression in a proband is influenced by the temporal sequence of comorbid PD and major depression in an affected family member. Methods: Of participants in a larger study of individuals who had a family, but no personal history of PD, 31 had a first-degree relative with comorbid PD and major depressive disorder (MDD). In 16, the onset of MDD preceded PD (HR-MDPD), and in 15, PD was established before the first depressive episode (HR-PDMD). Thirty-seven low-risk controls (LRC) described no first-degree relatives with psychiatric illness. Participants were assessed using the SADS-LA and provided family history data on first-degree relatives. Results: High-risk subjects whose first-degree relative had temporally primary depression had a 50% chance of having had a major depressive episode. Those with a first-degree relative with primary panic and secondary depression were at no greater risk of having had a depression than were normal controls (6.7% and 5.4%, respectively). Limitations: The use of the family history method has the intrinsic weakness of relying solely on proband knowledge. Conclusion: The temporal relationship between comorbid panic and depression may play an important role in determining the familial risk for depression in family members.

Primary fibromyalgia and depression: The role of relatives in fibromyalgia

Abstract Objective. To compare a group of patients suffering from fibromyalgia (FM) with patients having a lumbar disc hernia (LDH) and with a control group of healthy subjects. We investigate of the presence psychiatric disorders and their relationship with FM. Psychiatric disorders were also investigated in first and second degree relatives of patients with FM. Methods. Thirty-four patients suffering from FM according to the American College of Rheumatology criteria, 30 patients with lumbar disc hernia (LDH) without fibromyalgia and 43 healthy subjects were introduced into the study. All the groups were sex and age matched. All subjects were investigated by a structured clinical interview (Diagnostic and Statistical Manual of Mental Disorders, 4th edn), by Beck depression scale (BDS), and by Hamilton depression scale (HDS). Family history research diagnostic criteria were used. Results. The mean scores of BDS and of HDS were significantly higher in FM and LDH patients than in controls. In addition, ther...

Prediction of the response to citalopram and reboxetine in post-stroke depressed patients: the reasons of the enrollment of patients without cognitive impairment

Depression is frequently observed either as a primitive pathology or as a complication of cerebrovascular disorders. Current nosographical classification of depressions does not supply information based on a supposed clinical– biochemical correlation, which could be useful to select appropriate therapeutic options. Similarly to what described for primary depression (Rampello et al. 1991, 1995), we attempted to characterize different subtypes of post-stroke depression, i.e. anxious or retarded post-stroke depression (Rampello et al. 2004), in order to predict the therapeutic response to specific pharmacological treatments, taking into account the safety and tolerability of drugs, as well as the age and possible comorbidity in post-stroke depressed patients. Spalletta and Caltagirone (2003) argued that the enrollment of patients without cognitive deficit or with very mild cognitive impairment could be a limitation in our study. We excluded patients with MMSE score <22 for a number of reasons. First, the enrollment of patients with mild-to-severe cognitive impairment would have made the characterization of the two subtypes of depression difficult. In addition, the inclusion of these patients would have seriously complicated the evaluation of drug treatment. Thus, although the suggestion of Spalletta and Caltagirone is interesting and warrants further examination, the aim of our study was to select post-stroke depressed patients according to particular clinical profiles that are predictive of therapeutic response.

Diagnosing comorbid psychiatric disorders in substance abusers: validity of the Spanish versions of the Psychiatric Research Interview for Substance and Mental Disorders and the Structured Clinical Interview for DSM-IV.

The authors' goal was to assess the validity of DSM-IV diagnoses obtained with the Spanish versions of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) and the Structured Clinical Interview for DSM-IV (SCID) compared with the longitudinal, expert, all data (LEAD) procedure in a group of substance abusers. A total of 105 substance abusers recruited at a drug abuse treatment center in Barcelona, Spain, were assessed. The PRISM and SCID were administered blindly by independent research interviewers. LEAD diagnoses were made by two senior psychiatrists who were blind to PRISM and SCID diagnoses. The kappa statistic was used to measure concordance between the LEAD procedure and the PRISM and SCID. Affective and anxiety disorders were diagnosed more frequently by the PRISM and SCID than by the LEAD procedure. Use of the PRISM resulted in more diagnoses of substance-induced depression, and use of the SCID resulted in more diagnoses of primary major depression than the LEAD procedure. Kappas between the LEAD procedure and the PRISM in current major depression, past substance-induced depression, and borderline personality disorder were better than those obtained between the LEAD procedure and the SCID. The concordance among the three methods for diagnoses of current dependence disorders was good or excellent for alcohol, anxiolytic, cocaine, and heroin dependence and fair for cannabis dependence. Abuse diagnoses showed poor concordance. Using the LEAD procedure as a "gold standard," the authors conclude that the Spanish version of the PRISM seems to be a better instrument than the Spanish version of the SCID for diagnosing major depression and borderline personality disorders in substance abusers.

Causal Models for Randomized Physician Encouragement Trials in Treating Primary Care Depression

This article addresses unique causal issues in the context of a randomized study on improving adherence to best practice guidelines by primary care physicians (PCP's) in treating their depressed patients. The study assessed an encouragement strategy to improve PCP guideline adherence. In this context, we compare two causal approaches: the conditional-compliance (CC) Bayesian latent class and the conditional-observable (CO) structural mean model methods. The CC methods estimate contrasts between randomized encouragement and no-encouragement arms [intent-to-treat (ITT) estimand] given latent PCP guideline complier classes. The CO methods estimate contrasts between PCP guideline adherence and nonadherence conditions (as-treated estimand) given observed PCP adherence status. The CC ITT estimand for patients with PCP compliers equals the CO as-treated estimand depending on assumptions. One such assumption pertains to the absence of physician defiers, who do the opposite of what they are encouraged to do in treating patients for depression. We relate these two estimands to each other in our clinical context when the no-defier assumption is not plausible. In other contexts, previous statistical literature has appropriately assumed the absence of defiers. However, indications in the behavioral literature, anecdotal evidence in the study, and results from the data analysis and simulations suggest that defiers do exist in the context of physician-based interventions in primary care. Both simulation and empirical results show that even with a small estimated proportion of defiers under Bayesian model assumptions, inference is sensitive to different assumptions about this class of PCP noncompliers.

The Course of Depression in Elderly Patients

<h3>Objective</h3> Studies on the course of major depressive disorder (MDD) among elderly persons are limited to short periods of follow-up, seldom provide comparisons with younger cohorts, and raise other methodological concerns. <h3>Methods</h3> Utilizing 15 years of prospective data from the NIMH Collaborative Depression Study, the authors examined the index episode of MDD and the time until first observed recurrence in those who recovered for subjects in four age-groups defined by age at intake: 17–30, 31–50, 51–64, and 65–79 years. Assessments were conducted every 6 months for 5 years and annually thereafter. Survival analysis examined time until recovery and time to first recurrence. <h3>Results</h3> Median time-to-recovery was similar for the four groups. Median time-to-first recurrence was significantly shorter for oldest versus the 51–64-year-old group but not the two other groups. The oldest age-group was distinguished from the younger groups by being more likely to be divorced/widowed/separated, to have primary depression, and to have a history of medical illness, particularly cardiovascular disease or cancer. There was no difference in the generally low levels of pharmacotherapy prescribed during the index episode or the subsequent well interval. <h3>Conclusions</h3> Elderly patients with MDD may have a greater risk of recurrence than younger individuals. Low levels of treatment characterize the somatic treatment in all the study subjects, regardless of age-group.

Differential DSM-III Psychiatric Disorder Prevalence Profiles in Dystonia and Parkinson's Disease

The authors investigated the prevalence of DIS-ascertained DSM-III psychiatric disorders occurring in 28 patients with dystonia and 28 patients with Parkinson’s Disease (PD). In patients with dystonia, lifetime prevalences of major depression (25.0%), bipolar disorder (7.1%), atypical bipolar disorder (7.1%), social phobia (17.9%), and generalized anxiety disorder (25.0%) were significantly more common than in epidemiologic catchment area (ECA) study population controls (p < 0.005). Social phobia and generalized anxiety disorder preceded dystonia (primary), while bipolar disorder developed after dystonia onset (secondary). In PD patients, the lifetime prevalence of simple phobia (35.7%, p < 0.0001) and atypical depression (21.4%) were significantly more common. Parkinson’s Disease was associated with primary simple phobia and secondary atypical depression. These findings are considered in light of previous results and in terms of the differences in pallidothalamic physiologies in dystonia and PD. These data suggest distinctive profiles of psychiatric disorders in dystonia and PD.

Modern treatments for severe depression still have poor long term outcome

Kennedy N, Abbott R, Paykel ES. Remission and recurrence of depression in the maintenance era: long-term outcome in a Cambridge cohort. Psychol Med 2003;33:827–38.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Q Has the long...

The Course of Depression in Elderly Patients

Studies on the course of major depressive disorder (MDD) among elderly persons are limited to short periods of follow-up, seldom provide comparisons with younger cohorts, and raise other methodological concerns. Utilizing 15 years of prospective data from the NIMH Collaborative Depression Study, the authors examined the index episode of MDD and the time until first observed recurrence in those who recovered for subjects in four age-groups defined by age at intake: 17-30, 31-50, 51-64, and 65-79 years. Assessments were conducted every 6 months for 5 years and annually thereafter. Survival analysis examined time until recovery and time to first recurrence. Median time-to-recovery was similar for the four groups. Median time-to-first recurrence was significantly shorter for oldest versus the 51-64-year-old group but not the two other groups. The oldest age-group was distinguished from the younger groups by being more likely to be divorced/widowed/separated, to have primary depression, and to have a history of medical illness, particularly cardiovascular disease or cancer. There was no difference in the generally low levels of pharmacotherapy prescribed during the index episode or the subsequent well interval. Elderly patients with MDD may have a greater risk of recurrence than younger individuals. Low levels of treatment characterize the somatic treatment in all the study subjects, regardless of age-group.

Does elimination of placebo responders in a placebo run-in increase the treatment effect in randomized clinical trials? A meta-analytic evaluation.

The use of a placebo run-in phase, in which placebo responders are withdrawn from a study before random assignment to treatment condition, has been criticized as favoring the active treatment in clinical trials. We compared the effect size of randomized, placebo-controlled clinical trials (in the treatment of depression with selective serotonin reuptake inhibitors [SSRIs]) that include a placebo run-in phase with those that do not, using a meta-analytic approach. This study differed from earlier meta-analytic studies in that it considered only SSRIs and included only studies using continuous measures of depression, allowing for a more refined assessment of effect size. An extensive literature search identified 43 datasets published between 1980 and 2000 comparing placebo with SSRI and using a continuous measure of depression (usually the Hamilton Depression Rating Scale). We included only studies of at least 6 weeks' duration focusing on treatment for primary acute major depression in adults 18-65 years of age. Studies focusing on depression in specific medical illnesses were not included. Analysis of efficacy was based on 3047 subjects treated with an SSRI antidepressant and 3740 subjects treated with a placebo. There was no statistically significant difference in effect size between the clinical trials that had a placebo run-in phase followed by withdrawal of placebo responders and those trials that did not. Despite the lack of a statistically significant difference between studies of withdrawing early placebo responders and those not using this procedure, this approach is likely to continue to be used widely because it produces large absolute effect sizes. It is recommended that future studies clearly describe these procedures and report the number of subjects dropped from the study for early placebo response and other reasons.

Selective 6-OHDA induced dopaminergic lesioning increases depressive behavior in rats

Depression is the most common psychiatric disturbance in Parkinson's disease (PD), affecting approximately 40–50% of PD-patients. The manifestations include apathy, psychomotor retardation, memory impairment, pessimism, irrationality, and suicidal ideation without suicidal behaviour. Depression has been strongly related to the patients' quality of life in Parkinson's disease. The symptoms of depression in Parkinson's disease vary slightly from the typical symptom profile of primary depression.

Comparison of isoflurane and propofol–fentanyl anaesthesia in a swine model of asphyxia

There have been few studies comparing the response to asphyxia and the effectiveness of typical cardiopulmonary resuscitation (CPR) using exogenous epinephrine administration and manual closed-chest compression between total intravenous anaesthesia (TIVA) and inhalational anaesthesia. Twenty pigs were randomly assigned to two study groups anaesthetized using either 2% end-tidal isoflurane (n=10) or propofol (12 mg x kg(-1) h(-1))-fentanyl (50 microg x kg(-1)) (n=10). Asphyxia was induced by clamping the tracheal tube until the mean arterial pressure (MAP) decreased to 40% of the baseline value (40% MAP time). The tracheal tube was declamped at that point, and CPR was performed. Haemodynamic parameters and blood samples were obtained before the induction of asphyxia, at 1-min intervals during asphyxia, and 1, 2, 3, 5, 10, 30 and 60 min after asphyxia. TIVA maintained the MAP against hypoxia-hypercapnia stress significantly longer than isoflurane anaesthesia (mean (SD) 40% MAP time 498 (95) and 378 (104) s respectively). In all animals in the isoflurane group, spontaneous circulation returned within 1 min of the start of CPR. In six of the TIVA animals, spontaneous circulation returned for 220 (121) s; spontaneous circulation did not return within 5 min in the remaining four animals. Although TIVA is less prone than isoflurane anaesthesia to primary cardiovascular depression leading to asphyxia, TIVA is associated with reduced effectiveness of CPR in which resuscitation because of asphyxic haemodynamic depression occurs.