Relapse Of Major Depressive Disorder Research Articles

Transcranial direct current stimulation (tDCS) for preventing major depressive disorder relapse: Results of a 6-month follow-up

The efficacy of transcranial direct current stimulation (tDCS) as a continuation therapy for the maintenance phase of the depressive episode is low and insufficiently investigated in literature. We investigated whether it could be enhanced by using a more intensive treatment regimen compared to previous reports. Twenty-four patients (16 with unipolar depression and eight with bipolar depression) who presented acute tDCS response (≥50% depression improvement in the Hamilton Depression Rating Scale [HDRS]) after receiving 15 tDCS sessions were followed for up to 6 months or until relapse, defined as clinical worsening and/or HDRS>15. Sessions were performed twice a week (maximum of 48 sessions) over 24weeks. The anode and the cathode were positioned over the left and right dorsolateral prefrontal cortex (2mA current, 30 min sessions were delivered). We performed Kaplan-Meier survival analysis and Cox proportional hazards ratios to evaluate predictors of relapse. Out of 24 patients, 18 completed the follow-up period. tDCS treatment was well tolerated. The mean survival duration was 17.5weeks (122 days). The survival rate at the end of follow-up was 73.5% (95% confidence interval, 50-87). A trend (P=0.09) was observed for lower relapse rates in nontreatment- vs. antidepressant treatment-resistant patients (7.7%vs. 45.5%, respectively). No differences in efficacy between unipolar and bipolar depression were observed. An intensive tDCS treatment regimen consisting of sessions twice a week achieved relatively low relapse rates after a 6-month follow up of tDCS responders, particularly for nontreatment-resistant patients.

The role of selective serotonin reuptake inhibitors and cognitive behavioral therapy in preventing relapse of Major Depressive Disorder

In the mental health profession, the effectiveness of selective serotonin reuptake inhibitors and cognitive behavioral therapy in preventing relapse of Major Depressive Disorder play a key role; however, its role effectiveness is not known clearly. The objective of this review to assess the efficacy of selective serotonin reuptake inhibitors (SSRIs), and the role of cognitive behavioral therapy preventing relapse after an episode of major depressive disorder (MDD). This literature review was completed using electronic databases, an Ovid Medline and PsycINFO search. The current study analysis reviewed 250 abstracts and 25 full-text articles from the year 1987 to 2018. The search was conducted using keywords the selective serotonin reuptake inhibitors, antidepressants, cognitive behavioral therapy for major depressive disorder, major depressive disorder, prevention, treatment of depression, and relapse. Authors reviewed selected 16 articles after excluding after excluding 9 articles in refinement procedure to find the good fit of selected articles with inclusive criteria. Nine research articles compared the relapse rate of selective SSRIs with SSRIs and placebos; two discussed the effectiveness of SSRIs plus psychotherapy, two compared SSRI versus tricyclic antidepressants (TCAs), two were mainly composed of TCAs plus psychotherapy, and one compared SSRIs and serotonin- norepinephrine reuptake inhibitors (SNRIs). Among the studies included demonstrated lowered relapse risk in adults, when SSRIs combined with psychotherapy. The results comparing SSRIs, and SNRIs no differences observed. Basing reviewed facts study conclude TCAs are equally effective as SSRIs. Atypical antidepressants showed no efficacy differences with regard to remission rates compared with SSRIs. Review analysis indicated the Escitalopram as better efficacy than other SSRIs, seen with higher prophylactic efficacy and lower side effects; though the current data not showed significance. The current study concludes that continuing SSRIs treatment as maintenance for a year reduces the risk of MDD and relapse episodes. This study also clinches the combination of SSRIs and cognitive behavioural therapy may effectively reduce relapse. Additionally, evidenced Escitalopram has fewer side effects than did other SSRIs or SNRIs. Current review study concluded, regarding the effectiveness in reducing relapse of SSRIs is similar to that of TCAs, and atypical antidepressants.

Update on Randomized Placebo-Controlled Trials in the Past Decade for Treatment of Major Depressive Disorder in Child and Adolescent Patients: A Systematic Review.

Objectives: Antidepressant treatment for major depressive disorder (MDD) has been a topic of continued interest with a number of placebo randomized-controlled trials (RCTs) being published in the past decade. We review the updated literature since the 2007 Bridge meta-analysis, and reassess safety data looking at signals of treatment-emergent suicidality with the Columbia Suicide Severity Rating Scale (CSSR-S). Methods: PubMed literature review was performed searching for RCTs published since the 2007 article and supplemented with manual search. Results: Findings from seven trials (five industry sponsored, one NIMH funded, and one other) were included in this systematic review, which showed high medication and placebo response rates, with only fluoxetine and escitalopram treatment reaching statistical significance. Fluoxetine was also shown to prevent relapse of MDD with continued treatment with an odds ratio of 3.2 for prevention of relapse compared with placebo. There were no increases in treatment-emergent suicidality associated with antidepressant medication in any trial measuring suicidality systematically using the CSSR-S. Conclusions: Depressed pediatric patients respond similarly in these trials to antidepressant intervention and placebo, with recent studies showing that newer agents did not clearly demonstrate benefit above placebo. The evidence continues to support fluoxetine and escitalopram as first-line treatment and demonstrated effect to prevent relapse. Use of newer rating scales reveals similar rates of treatment-emergent suicidality in patients on antidepressants as placebo, in contrast to increased suicide signal suggested by past research using adverse events data. Antidepressant treatment is generally safe and well tolerated in this age group.

Association of Brain Cortical Changes With Relapse in Patients With Major Depressive Disorder

ImportanceMore than half of all patients with major depressive disorder (MDD) experience a relapse within 2 years after recovery. It is unclear how relapse affects brain morphologic features during the course of MDD.ObjectiveTo use structural magnetic resonance imaging to identify morphologic brain changes associated with relapse in MDD.Design, Setting, and ParticipantsIn this longitudinal case-control study, patients with acute MDD at baseline and healthy controls were recruited from the University of Münster Department of Psychiatry from March 21, 2010, to November 14, 2014, and were reassessed from November 11, 2012, to October 28, 2016. Depending on patients’ course of illness during follow-up, they were subdivided into groups of patients with and without relapse. Whole-brain gray matter volume and cortical thickness of the anterior cingulate cortex, orbitofrontal cortex, middle frontal gyrus, and insula were assessed via 3-T magnetic resonance imaging at baseline and 2 years later.Main Outcomes and MeasuresGray matter was analyzed via group (no relapse, relapse, and healthy controls) by time (baseline and follow-up) analysis of covariance, controlling for age and total intracranial volume. Confounding factors of medication and depression severity were assessed.ResultsThis study included 37 patients with MDD and a relapse (19 women and 18 men; mean [SD] age, 37.0 [12.7] years), 23 patients with MDD and without relapse (13 women and 10 men; mean [SD] age, 32.5 [10.5] years), and 54 age- and sex-matched healthy controls (24 women and 30 men; mean [SD] age, 37.5 [8.7] years). A significant group-by-time interaction controlling for age and total intracranial volume revealed that patients with relapse showed a significant decline of insular volume (difference, −0.032; 95% CI, −0.063 to −0.002; P = .04) and dorsolateral prefrontal volume (difference, −0.079; 95% CI, −0.113 to −0.045; P < .001) from baseline to follow-up. In patients without relapse, gray matter volume in these regions did not change significantly (insula: difference, 0.027; 95% CI, −0.012 to 0.066; P = .17; and dorsolateral prefrontal volume: difference, 0.023; 95% CI, −0.020 to 0.066; P = .30). Volume changes were not correlated with psychiatric medication or with severity of depression at follow-up. Additional analysis of cortical thickness showed an increase in the anterior cingulate cortex (difference, 0.073 mm; 95% CI, 0.023-0.123 mm; P = .005) and orbitofrontal cortex (difference, 0.089 mm; 95% CI, 0.032-0.147 mm; P = .003) from baseline to follow-up in patients without relapse.Conclusion and RelevanceA distinct association of relapse in MDD with brain morphologic features was revealed using a longitudinal design. Relapse is associated with brain structures that are crucial for regulation of emotions and thus needs to be prevented. This study might be a step to guide future prognosis and maintenance treatment in patients with recurrent MDD.

A Promising Future Role for Neuroimaging in Tracking and Predicting Relapse in Major Depressive Disorder

A Promising Future Role for Neuroimaging in Tracking and Predicting Relapse in Major Depressive Disorder

The effect of CBT and its modifications for relapse prevention in major depressive disorder: a systematic review and meta-analysis

BackgroundThe risk of relapse in major depressive disorder (MDD) is associated with high worldwide disease burden. Cognitive behavioral therapy (CBT) and its modifications might be effective in relapse prevention. The aim of this review was to evaluate the efficacy of these treatments for reducing relapse of MDD.MethodsThe retrieval was performed in the databases of MEDLINE via Pubmed, EMBASE and PsycINFO via OVID, The Cochrane Library and four Chinese databases. Clinical trials registry platforms and references of relevant articles were retrieved as well. Hazard ratio (HR) and corresponding 95% confidence interval (CI) were used to pool evidences.ResultsA total of 16 eligible trials involving 1945 participants were included. In the first 12 months, CBT was more efficacious than control in reducing the risk of developing a new episode of depression for MDD patients in remission (HR:0.50, 95%CI:0.35–0.72, I2 = 11%). Mindfulness-based cognitive therapy (MBCT) was more efficacious than control only among patients with 3 or more previous depressive episodes (HR:0.46, 95%CI:0.31–0.70, I2 = 38%). Besides, compared with maintenance antidepressant medication (m-ADM), MBCT was a more effective intervention (HR:0.76, 95%CI:0.58–0.98, I2 = 0%). These positive effects might be only maintained at two and nearly 6 years follow up for CBT.ConclusionThe use of CBT for MDD patients in remission might reduce risk of relapse. Besides, the effect of MBCT was moderated by number of prior episodes and MBCT might only be effective for MDD patients with 3 or more previous episodes. Further exploration for the influence of previous psychological intervention is required.

The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder.

The objective of this review was to evaluate the efficacy of selective serotonin reuptake inhibitors (SSRIs) and SSRIs compared with other treatment modalities in preventing relapse after an episode of major depressive disorder (MDD). An Ovid MEDLINE and PsycINFO search (from 1987 to August 2017) was conducted using the following terms: selective serotonin reuptake inhibitors, antidepressants, depression, prevention, prophylaxis, relapse and MDD. Using predefined criteria, two authors independently selected and reached consensus on the included studies. Sixteen articles met the criteria: 10 compared the relapse rate of selective SSRIs with placebo or other SSRIs; one discussed the effectiveness of SSRIs plus psychotherapy, two compared SSRI versus tricyclic antidepressants (TCAs), two were mainly composed of TCAs plus psychotherapy, and one compared SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs). According to the included studies, the relapse risk in adults was lower when SSRIs were combined with psychotherapy. Results comparing SSRIs and SNRIs were inconclusive. TCAs may be equally as effective as SSRIs. Atypical antidepressants (mirtazapine and St John's Wort) had no significant difference in efficacy and remission rates compared with SSRIs. Escitalopram appeared to fare better in efficacy than other SSRIs, owing to a higher prophylactic efficacy and lower side effects; however, according to the current data, this difference was not significant. To conclude, this review provides evidence that continuing SSRIs for 1 year reduces risk of MDD and relapse. Furthermore, the combination of SSRIs and cognitive behavioural therapy may effectively reduce relapse. Escitalopram appeared to yield better results and fewer side effects than did other SSRIs or SNRIs. The effectiveness in reducing relapse of SSRIs was similar to that of TCAs and atypical antidepressants.

Initial Steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder

Responders to acute-phase cognitive therapy (A-CT) for major depressive disorder (MDD) often relapse or recur, but continuation-phase cognitive therapy (C-CT) or fluoxetine reduces risks for some patients. We tested composite moderators of C-CT versus fluoxetine's preventive effects to inform continuation treatment selection. Responders to A-CT for MDD judged to be at higher risk for relapse due to unstable or partial remission (N=172) were randomized to 8 months of C-CT or fluoxetine with clinical management and assessed, free from protocol treatment, for 24 additional months. Pre-continuation-treatment characteristics that in survival analyses moderated treatments’ effects on relapse over 8 months of continuation-phase treatment (residual symptoms and negative temperament) and on relapse/recurrence over the full observation period's 32 months (residual symptoms and age) were combined to estimate the potential advantage of C-CT versus fluoxetine for individual patients. Assigning patients to optimal continuation treatment (i.e., to C-CT or fluoxetine, depending on patients’ pre-continuation-treatment characteristics) resulted in absolute reduction of relapse or recurrence risk by 16–21% compared to the other non-optimal treatment. Although these novel results require replication before clinical application, selecting optimal continuation treatment (i.e., personalizing treatment) for higher risk A-CT responders may decrease risks of MDD relapse and recurrence substantively.

Randomized, proof-of-concept trial of low dose naltrexone for patients with breakthrough symptoms of major depressive disorder on antidepressants

BackgroundGiven the proposed dopaminergic mechanism of low-dose naltrexone (LDN), we examined its efficacy as augmentation for depressive breakthrough on pro-dopaminergic antidepressant regimens. Methods12 adults (67% female, mean age = 45±12) with recurrent DSM-IV major depressive disorder (MDD) on dopaminergic antidepressant regimens (stimulants, dopamine agonists, bupropion [≥300mg/day], aripiprazole [≤2.5mg/day], or sertraline [≥150mg/day]) were randomized to naltrexone 1mg b.i.d. (n=6) or placebo (n=6) augmentation for 3 weeks. ResultsAll subjects completed the trial. Hamilton Depression Rating Scale (HAM-D-17) scores (primary outcome measure) decreased from 21.2±2.0 to 11.7±7.7 for LDN, from 23.7±2.3 to 17.8±5.9 for placebo (Cohen's d=0.62; p=0.3 between treatment groups). HAM-D-28 scores decreased from 26.2±4.0 to 12.0±9.8 for LDN, from 26.3±2.6 to 19.8±6.6 for placebo (d=1.15; p=0.097). Montgomery-Asberg Depression Rating Scale (MADRS-10 item) scores decreased from 30.4±4.9 to 12.2±8.4 for LDN, from 30.7±4.3 to 22.8±8.5) for placebo (d=1.45; p=0.035). MADRS-15 item scores decreased from 36.6±6.2 to 13.2±8.8 for LDN, from 36.7±4.2 to 26.0±10.0 for placebo (d=1.49; p=0.035). Clinical Global Improvement Scale-Severity (CGI-S) scores decreased from 4.3±0.5 to 3.0±1.1 for LDN, from 4.3±0.5 to 4.0±0.6 for placebo (d=1.22; p=0.064). LimitationsSmall study; restrictions on allowed antidepressants. ConclusionLDN augmentation showed some benefit for MDD relapse on dopaminergic agents. Confirmation in larger studies is needed.

Recurrent Major Depressive Disorder of a Young Woman.

Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

An Introduction to the Buddhist Underpinnings of Mindfulness-Based Interventions: Buddha-Nature and Intrinsic Goodness

An Introduction to the Buddhist Underpinnings of Mindfulness-Based Interventions: Buddha-Nature and Intrinsic Goodness

Are SSRIs during pregnancy safe? More studies seek answers

Are SSRIs during pregnancy safe? More studies seek answers

Psychotherapy after acute pharmacotherapy reduces relapse in depression

A meta‐analysis encompassing 13 studies has found that administration of psychotherapy following successful acute‐phase pharmacotherapy constitutes a viable strategy for preventing relapse in major depressive disorder. Outcomes in the studies were generally encouraging whether psychotherapy was administered with or without continuation treatment with an antidepressant.

Integrating CBT, Pharmacotherapy May Prevent Relapse in MDD

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessIntegrating CBT, Pharmacotherapy May Prevent Relapse in MDDVabren WattsVabren WattsSearch for more papers by this authorPublished Online:4 Dec 2015https://doi.org/10.1176/appi.pn.2015.12a4AbstractA meta-analysis identifies a treatment combination involving cognitive-behavioral therapy that may help patients with major depressive disorder stave off relapse.Patients with major depressive disorder (MDD) who participate in psychotherapy after responding to acute-phase pharmacotherapy may have a lower risk of relapse and recurrence when tapering antidepressants, according to a meta-analysis published October 20 in AJP in Advance.Researchers from the University of Bologna in Italy and University of New York, Buffalo, performed a systematic review of randomized, controlled trials that examined the effectiveness of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD.“The results of this meta-analysis provide new, important clinical insights into the role of psychotherapy in the treatment of depression,” said lead author Jenny Guidi, Ph.D., a professor of psychology and education sciences at the University of Bologna. “The sequential modality of integration of pharmacotherapy and psychotherapy appears to be a valuable therapeutic strategy for preventing relapse in major depressive disorder.”Key PointsThe authors analyzed 13 trials examining the effectiveness of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with major depressive disorder. All trials involved cognitive-behavioral therapy (CBT).Patients who received CBT while antidepressants were tapered or discontinued were significantly less likely to experience relapse or recurrence compared with those assigned to either clinical management during tapering of antidepressants or continuation of antidepressant medication. The number needed to treat (NNT) for the CBT plus drug tapering/discontinuation group was 5 compared with an NNT of 10 among those who continued pharmacotherapy.Bottom line: Sequential integration of psychotherapy after acute treatment with pharmacotherapy may serve as an effective method in preventing relapse in adults with major depressive disorder.For the study, Guidi and colleagues analyzed 13 trials (including 1,410 participants aged 18 and older with no history of comorbid psychiatric illness)—all of which involved cognitive-behavioral therapy (CBT) after an acute-phase of pharmacotherapy. They found that patients who were randomly assigned to receive CBT while antidepressants were discontinued were significantly less likely to experience relapse or recurrence compared with those assigned to either clinical management during tapering of antidepressants or continuation of antidepressant medication. The number needed to treat (NNT)—the average number of patients who need to be treated to prevent one unfavorable health outcome—for the CBT plus drug tapering/discontinuation group was 5 compared with an NNT of 10 among those who continued pharmacotherapy, suggesting a greater advantage associated with the sequential option of drug tapering/discontinuation in preventing relapse or recurrence than with continuation of antidepressants.“The average depressed patient appears to express stronger preferences for psychotherapy than for antidepressant medications, a finding that is of considerable clinical importance given that treatment preference is a potent moderator of response to therapy,” the study authors wrote.“There is urgent need for studies comparing continuation and discontinuation of antidepressant drugs during the application of the psychotherapeutic approach in the residual phase of depressive illness,” said Guidi. “There is also a need to compare different strategies—such as psychotherapy alone, pharmacotherapy alone, and their simultaneous or sequential integration in head-to-head comparisons. The efficacy of the sequential use of other well-established psychotherapies after response to pharmacotherapy need to be tested as well.” The study was supported in part by Compagnia di San Paolo, a bank foundation in Italy. ■“The Sequential Integration of Pharmacotherapy and Psychotherapy in the Treatment of Major Depressive Disorder: A Meta-Analysis of the Sequential Model and a Critical Review of the Literature” can be accessed here. ISSUES NewArchived

Acquainted with the night again and again: key factors associated with relapse in major depressive disorder.

M depression is one of the most prevalent neuropsychiatric disorders in the United States with significant morbidity, and in 2012 approximately 16 million adults 18 years and older experienced at least 1 major depressive episode.1 According to the World Health Organization, major depression is also considered the disease that carries the heaviest disability burden among all neurobehavioral disorders, and it accounts for approximately 8.3% of all US years lived with a disability.2 Unfortunately, as noted by Figueroa et al3 in this issue of the Journal, the challenge of preventing relapse in major depressive disorder (MDD) may be greater than treating acute episodes, particularly given the fact that MDD relapse becomes progressively more frequent over time in individuals, with decreasing remission duration.4 In addition, Mueller et al5 noted that the rate of MDD relapse is quite high, as high as 80%, and that relapse is common, even during events in which a modifier such as postpartum depression is used in MDD.6,7 Such a high relapse rate may be the result of lack of treatment efficacy responsible for residual symptoms or other factors not properly addressed for a large percentage of patients with a first and recurrent major depressive episode. At an experiential and personal level, our patients frequently tell us that the recurring nature of MDD takes an overwhelming toll on their emotional and adaptive wellbeing, which makes MDD feel like other highly debilitating, chronic medical conditions. The question then arises, What variables have been investigated as potentially responsible or representing enhanced risk for MDD relapse?

The Sequential Integration of Pharmacotherapy and Psychotherapy in the Treatment of Major Depressive Disorder: A Meta-Analysis of the Sequential Model and a Critical Review of the Literature

A number of randomized controlled trials in major depressive disorder have employed a sequential model, which consists of the use of pharmacotherapy in the acute phase and of psychotherapy in its residual phase. The aim of this review was to provide an updated meta-analysis of the efficacy of this approach in reducing the risk of relapse in major depressive disorder and to place these findings in the larger context of treatment selection. Keyword searches were conducted in MEDLINE, EMBASE, PsycINFO, and Cochrane Library from inception of each database through October 2014. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with major depressive disorder were considered for inclusion in the meta-analysis. Thirteen high-quality studies with 728 patients in a sequential treatment arm and 682 in a control treatment arm were included. All studies involved cognitive-behavioral therapy (CBT). The pooled risk ratio for relapse/recurrence was 0.781 (95% confidence interval [CI]=0.671-0.909; number needed to treat=8), according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence compared with control conditions. A significant effect of CBT during continuation of antidepressant drugs compared with antidepressants alone or treatment as usual (risk ratio: 0.811; 95% CI=0.685-0.961; number needed to treat=10) was found. Patients randomly assigned to CBT who had antidepressants tapered and discontinued were significantly less likely to experience relapse/recurrence compared with those assigned to either clinical management or continuation of antidepressant medication (risk ratio: 0.674; 95% CI=0.482-0.943; number needed to treat=5). The sequential integration of CBT and pharmacotherapy is a viable strategy for preventing relapse in major depressive disorder. The current indications for the application of psychotherapy in major depressive disorder are discussed, with special reference to its integration with pharmacotherapy.

Vortioxetine in the treatment of major depressive disorder

ABSTRACT Vortioxetine is a novel psychotropic drug, with evidence of efficacy in acute treatment of major depressive episodes and in prevention of relapse in major depressive disorder. It has been described as having a ‘multimodal’ serotonergic mechanism of action, involving reuptake inhibition and a range of effects on presynaptic and postsynaptic receptors. It also has important effects on other neurotransmitters thought to be important in the neurobiology of depression and response to antidepressant treatment. It is efficacious in reducing anxiety symptom severity in depressed patients. The tolerability profile of vortioxetine appears predictable from its pharmacological properties. It may have beneficial effects in improving ‘cognition’ in depression, and a lower incidence of treatment-emergent sexual dysfunction, but these potential benefits require further investigation.

Circadian typology and depressive disorders. A non negligible association

Circadian typology (morning, neither and evening-type) is an individual difference related to several aspects of mental health. We present a comprehensive review of the findings published about circadian typology, major depressive disorder and seasonal affective disorder. Circadian typology is related to begin, course, remission and relapse of major depressive disorder and seasonal affective disorder. Evening-type subjects have a higher prevalence of depressive symptomatology and suicidal ideation, showing more severe symptoms than morning- and neither-type with the same diagnostic, suggesting that this typology could represent a risk factor for the development of psychopathology. These individual differences may be explained by three factors: Clock gene polymorphisms, social jet lag and personality traits. Chronobiological therapy (behavioral habits, pharmacological therapy with melatonin and light therapy) has demonstrated hopeful results applied to depressive disorders when circadian rhythmicity is altered. Circadian typology should be taken into account in prevention programs and treatment of depressive disorders.

Impact of Sleep Complaints and Depression Outcomes Among Participants in the Standard Medical Intervention and Long-Term Exercise Study of Exercise and Pharmacotherapy for Depression

The aim of this study was to examine the effects of exercise and sertraline on disordered sleep in patients with major depressive disorder (MDD). Methods The Standard Medical Intervention and Long-term Exercise study randomized the patients with MDD (n = 202) to one of four arms: a) supervised exercise, b) home-based exercise, c) sertraline therapy, and d) placebo pill. Sleep disturbance was assessed with three sleep-related items from the Hamilton Rating Scale for Depression (HAM-D) before and after 4 months of treatment. The patients were followed for 12 months to assess the prognostic value of sleep disturbance on MDD relapse and recovery.Results Comparison of the active treatment and placebo groups showed no treatment differences in HAM-D sleep complaints after 4 months (p = 0.758). However, residual insomnia symptoms after treatment were strongly associated with elevated depressive symptoms assessed by the HAM-D after 4 months (β = 0.342, p < 0.0001) and MDD relapse (odds ratio, 1.55; 95% confidence interval, 1.15-2.10; p = 0.004) assessed at 1-year follow-up (16 months after randomization). Neither exercise nor sertraline was associated with greater improvements in sleep disturbance compared with the placebo controls. However, residual symptoms of insomnia after successful treatment of MDD predicted relapse, highlighting the clinical importance of addressing insomnia in patients with MDD.

Autoimmune-Mediated Cognitive Impairment: A Case Report

Autoimmune encephalopathy encompasses a complex groupof diseaseswith diverse clinicalmanifestations and therapeutic outcomes. Central nervous system (CNS) autoimmune inflammation can be triggered in multiple ways, including (1) systemic infections/vaccinations, (2) various cancers (paraneoplastic autoimmune encephalitis), (3) systemic autoimmunedisorders, and (4)without an identifiable cause (e.g., nonparaneoplastic autoimmune encephalitis). The discovery of neuropsychiatric disorders associated with antibodies to neuronal cell surface proteins, which play a crucial role in synaptic transmission and plasticity, has resulted in a paradigm shift in our understanding of CNS autoimmunity. We report a case of a young woman with multiple autoimmune disorders who presented with significant memory problems and relapse of major depressive disorder. Her cognitive problems did not resolve upon treatment of depression and continued to result in significant impairment of her daily functioning. A comprehensive neuropsychiatric and neurologic evaluation helped in establishing and providing a successful treatment. This case underscores the importance of recognizing neuropsychiatric manifestations of autoimmune disorders and the use of a multidisciplinary approach for the evaluation and treatment of neuropsychiatric conditions. Medicine, Baltimore, MD; Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH. Send correspondence and reprint requests to Bhargavi Devineni,M.B.B.S., Division of Geriatrics and Neuropsychiatry, Department of Psychiatry, Johns Hopkins University of Medicine, 5300 Alpha Commons Drive 4th Floor, Alpha Commons Building, Baltimore, MD 21224; e-mail: bdevine2@jhmi.edu & 2014TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Case Report