Residual Depressive Symptoms Research Articles

Mindfulness‐Based Cognitive Therapy for Nonremitted Patients with Bipolar Disorder

Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, many individuals with bipolar disorder continue to experience substantial residual mood symptoms that often lead to the recurrence of mood episodes. This study explored whether a new mindfulness-based cognitive therapy (MBCT) for bipolar disorder would increase mindfulness, reduce residual mood symptoms, and increase emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning. Following a baseline clinical assessment, 12 individuals with DSM-IV bipolar disorder were treated with 12 group sessions of MBCT. At the end of treatment, as well as at the 3 months follow-up, participants showed increased mindfulness, lower residual depressive mood symptoms, less attentional difficulties, and increased emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning. These findings suggest that treating residual mood symptoms with MBCT may be another avenue to improving mood, emotion regulation, well-being, and functioning in individuals with bipolar disorder.

Residual Symptoms in Depressed Outpatients Who Respond by 50% But Do Not Remit to Antidepressant Medication

Little is known about the quantity or quality of residual depressive symptoms in patients with major depressive disorder (MDD) who have responded but not remitted with antidepressant treatment. This report describes the residual symptom domains and individual depressive symptoms in a large representative sample of outpatients with nonpsychotic MDD who responded without remitting after up to 12 weeks of citalopram treatment in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Response was defined as 50% or greater reduction in baseline 16-item Quick Inventory of Depressive Symptomatology--Self-Report (QIDS-SR₁₆) by treatment exit, and remission as a final QIDS-SR₁₆ of less than 6. Residual symptom domains and individual symptoms were based on the QIDS-SR₁₆ and classified as either persisting from baseline or emerging during treatment. Most responders who did not remit endorsed approximately 5 residual symptom domains and 6 to 7 residual depressive symptoms. The most common domains were insomnia (94.6%), sad mood (70.8%), and decreased concentration (69.6%). The most common individual symptoms were midnocturnal insomnia (79.0%), sad mood (70.8%), and decreased concentration/decision making (69.6%). The most common treatment-emergent symptoms were midnocturnal insomnia (51.4%) and decreased general interest (40.0%). The most common persistent symptoms were midnocturnal insomnia (81.6%), sad mood (70.8%), and decreased concentration/decision making (70.6%). Suicidal ideation was the least common treatment-emergent symptom (0.7%) and the least common persistent residual symptom (17.1%). These findings suggest that depressed outpatients who respond by 50% without remitting to citalopram treatment have a broad range of residual symptoms. Individualized treatments are warranted to specifically address each patient's residual depressive symptoms.

P01-218 - An indian study of health related quality of life in bipolar disorder patients and their caregivers

IntroductionThere are major health care implications of quality of life (QOL) in longstanding disorders such as Bipolar affective disorder (BD) for the patients and their caregivers.ObjectivesThe aim of the present study is to compare quality of life among bipolar disorder patients, their caregivers and to assess whether the level of depression correlates with the scores of quality of life in Bipolar Disorder patients.MethodWe compared bipolar disorder (N = 40), their caregivers (N = 40) and no psychiatric illnesses (N = 150) on health related quality of life (HRQOL) which was assessed using the 26-item World Health Organization QOL instrument (WHOQOL-BREF Hindi version). All patients were diagnosed using the Structured Clinical Interview for DSM IV. Within the group with bipolar disorder, we examined the relationship between HRQOL using WHOQOL BREF Hindi version and depression assessed using the 17-item Hamilton Depression Rating Scale (HDRS).ResultsPatients in bipolar disorder group had lower QOL on all the four domains compared to healthy controls, caregivers. The four domains of the WHOQOL scale correlated negatively with the HDRS.ConclusionsOur findings suggest that bipolar depression and residual symptoms of depression are negatively correlated with QOL in BD patients.

Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder

Objectives The objectives of the present study were (1) to assess the impact of cognitive-behavior therapy (CBT) for posttraumatic stress disorder (PTSD) on associated sleep disturbances and (2) to explore the correlates of persistent sleep difficulties in terms of anxiety and depression symptoms and perceived health. Method Fifty-five individuals with PTSD were administered a series of assessments designed to evaluate sleep, PTSD symptoms, symptoms of anxiety and depression, and perceived health before and after individual CBT for PTSD and at 6-month follow-up. Results Significant improvements were observed on sleep quality, sleep onset latency, sleep efficiency, and sleep disturbances. These changes were not fully maintained after 6 months, and 70% of people who reported baseline sleep difficulties (Pittsburgh Sleep Quality Index >5) still reported significant problems with sleep after treatment. Persistent sleep difficulties were associated with more severe posttraumatic, anxious, and depressive symptoms as well as poorer health. Conclusion Although CBT for PTSD had a favorable impact on sleep, the majority of participants suffered from residual sleep difficulties. Individuals with persistent sleep difficulties posttreatment may experience more residual posttraumatic, depression, and anxiety symptoms and poorer mental and physical health than those who do not report sleep problems posttreatment. Further research in this area will allow clinicians to treat sleep problems in these individuals more effectively.

Residual symptoms after remission of major depressive disorder with fluoxetine and risk of relapse

Many patients with major depressive disorder (MDD) who achieve full remission after antidepressant treatment still have residual depressive symptoms. In this study, we assess the type and frequency of residual symptoms and their relationship to subsequent depressive relapses after remission of major depression with fluoxetine. Five hundred seventy-six patients with MDD were openly treated with fluoxetine for 12 weeks. Those who responded underwent random assignment, under double-blind conditions, to continue taking fluoxetine or to switch to placebo for 52 weeks or until relapse. The presence of residual symptoms in patients who achieved remission at the end of the acute phase (N=203) was assessed using the 28-item Hamilton Depression Rating Scale. Survival analysis was used to examine the effect of residual symptoms on relapse in remitters. More than 90% of patients who met criteria for remission had at least one residual depressive symptom (median=4). The most common were sleep disturbances (insomnia 48.2%, hypersomnia 35.9%) and anxiety (52.7%). The most common individual symptom was middle insomnia (33.5%). No statistically or clinically significant differences in baseline variables were found between remitters with and without residual symptoms. The presence of residual symptoms, the presence of residual insomnia and the global number of residual symptoms did not predict relapse during the continuation phase of the study. The great majority of patients with remission of MDD after treatment with fluoxetine continue to experience selected residual depressive symptoms. The presence of residual symptoms is not significantly associated with an increased risk of relapse.

Mechanisms of Change in Mindfulness-Based Cognitive Therapy for Depression: Preliminary Evidence from a Randomized Controlled Trial

Mindfulness-based cognitive therapy (MBCT) is an effective treatment for reducing depressive relapse as well as residual depressive symptoms among adults with recurrent depression but the specific mechanisms through which this treatment works have yet to be examined. This study investigated MBCT's immediate (pre to post) effects on depressive symptoms and its potential theory-driven change mechanisms in a wait-list randomized control trial. Recurrently depressed patients, the majority of them in partial remission, were randomized to either an 8-week MBCT group (N = 26) or a wait-list control group (N = 19). Participants completed measures of depressive symptoms as well as measures of rumination and trait mindfulness before and after the intervention. Consistent with the MBCT change theory, bootstrapping-based mediation analyses demonstrated that reductions in brooding (an aspect of rumination) and increases in mindfulness independently and uniquely (accounting for other mediators) mediated the effects of ...

Stratégie thérapeutique des épisodes dépressifs. Prévention du risque de récidive

Prevention of the risk of recurrence of depressive episodes is a dynamic process that begins early in the management. Although complete remission is obtained for almost half of the treated depressive episodes, a heuristic conceptual thinking apprehends depression as a potentially chronic disorder when considering relapse and recurrence prevention. Multiple actions of care have to be initiated. They are formalised, but also adjustable to the needs of a critical management period throughout the follow-up. These actions include the prescription of an antidepressant at an effective dosage. They also consider the preventative and therapeutic impact of psychotherapy. The search for residual symptoms of depression is the rule, and addition of other medication should be considered if needed. These recommendations are evidence-based in the context of recurrence prevention. Nevertheless, many other initiatives are equally important recommendations in terms of therapeutic impact. Thus, rigorous evaluation of the initial symptomatology, promotion of information on disease, health-care advices, as well as implementation of family and other networks are good-practices. Such actions should be conducted in a relationship based on a therapeutic alliance. These elements need to be adjusted and contextualised in line with the Health System, mode of medical practice and unique style of the therapist. Proactive and sustainable implementations of these guidelines are required in the context of a unique and open therapeutic relationship for both therapist and patient.

Dépression récurrente : facteurs de risque, facteurs de vulnérabilité

Major depressive disorder is a disease whose course is often chronic because the prevalence of recurrence is high. Therefore, it is important to know the risk factors of relapse (number of previous episodes, persistence of residual depressive symptoms…). Moreover, identifying factors of vulnerability of the disease may help to detect very-high-risk subjects in order to prevent the disease onset. Many hypothesis are explored: serotonin dysfunction, axis of stress, alteration of brain structures. Finally, antidepressant treatment is a protective factor and is efficient to limit the risk of chronicity.

Study protocol for a randomized controlled trial comparing mindfulness-based cognitive therapy with maintenance anti-depressant treatment in the prevention of depressive relapse/recurrence: the PREVENT trial

BackgroundDepression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. We need to develop psychological therapies that prevent depressive relapse/recurrence. A recently developed treatment, Mindfulness-based Cognitive Therapy (MBCT, see http://www.mbct.co.uk) shows potential as a brief group programme for people with recurring depression. In two studies it has been shown to halve the rates of depression recurring compared to usual care.This trial asks the policy research question, is MBCT superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and, secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? An explanatory research question asks is an increase in mindfulness skills the key mechanism of change?Methods/DesignThe design is a single blind, parallel RCT examining MBCT vs. m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT plus ADM-tapering with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre/post-treatment and a qualitative study of service users' views and experiences.DiscussionIf the results of our exploratory trial are extended to this definitive trial, MBCT will be established as an alternative approach to maintenance anti-depressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches.Trial registration numberISRCTN26666654

RESEARCH: Cognitive Rehabilitation for Bipolar Disorder: An Open Trial for Employed Patients with Residual Depressive Symptoms

Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, individuals with bipolar disorder often continue to experience impairments in psychosocial functioning, particularly occupational functioning. Two determinants of psychosocial functioning of euthymic (neither fully depressed nor manic) individuals with bipolar disorder are residual depressive symptoms and cognitive impairment (i.e., difficulties with executive functioning, attention, and memory). The present study explored whether a new cognitive remediation (CR) treatment designed to treat residual depressive symptoms and, for the first time to the best of our knowledge, address cognitive impairment would be associated with improvement in psychosocial functioning in individuals with bipolar disorder. Following a neuropsychological and clinical assessment 18 individuals with DSM-IV bipolar disorder were treated with 14 individual sessions of CR. Results indicated that at the end of treatment, as well as at the 3-months follow-up, patients showed lower residual depressive symptoms, and increased occupational, as well as overall psychosocial functioning. Pretreatment neuropsychological impairment predicted treatment response. Improvements in executive functioning were associated with improvements in occupational functioning. These findings suggest that treating residual depressive symptoms and cognitive impairment may be an avenue to improving occupational and overall functioning in individuals with bipolar disorder.

Functional impairment in bipolar II disorder: Is it as disabling as bipolar I?

Introduction It is well established that patients with bipolar disorder experience functional impairment even in remission. Nevertheless, bipolar II disorder remains understudied because most investigations to date include only bipolar I patients or just a small sample of bipolar II patients, without explicitly comparing both subtypes of disorder. The main objective of the current report is to evaluate overall and multiple domains of functioning, specifically in bipolar II disorder compared to patients with bipolar I disorder and healthy subjects. Methods 233 subjects from 3 groups were compared: bipolar I patients ( n = 106), bipolar II patients ( n = 66) and healthy controls ( n = 61). Bipolar patients meeting criteria of remission were recruited at the Hospital Clinic of Barcelona and at different study sites in Argentina. All participants were assessed with 17-item Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS) and the Functioning Assessment Short Test (FAST). Clinical and sociodemographic data were also recorded. Results Both subgroups of patients, bipolar I and bipolar II, showed lower overall functioning ( p < 0.001) and in each domain of the FAST scale (all, p < 0.001) when compared to the healthy control group. Tukey post hoc test revealed that bipolar II patients scored worse in the cognitive domain compared to bipolar I patients. However, after controlling for potential confounding variables, this difference disappeared and only older age ( p < 0.005) and HAM-D scores ( p < 0.001) remained significant. Conclusions Our results suggest that bipolar II patients are as disabled as bipolar I patients. This may be explained, in part, because bipolar II patients experience greater lifetime residual depressive symptoms than the bipolar I subgroup, which may have particular impact on cognitive domains of functioning.

Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms

Background Although extensive studies have indicated a relationship between obstructive sleep apnea (OSA) and depressive symptoms, the effect of continuous positive airway pressure (CPAP) treatment on residual depressive symptoms in patients with both major depressive disorder (MDD) and coexisting OSA has not been examined. Methods Seventeen patients with continued MDD despite pharmacotherapy such as antidepressants and/or benzodiazepines, who also had comorbid OSA, were required to complete the Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), and Epworth sleepiness scale (ESS) at the commencement of the study and then again after 2 months of CPAP treatment. Results BDI and HRSD scores decreased from 19.7 to 10.8 and 16.7 to 8.0 after 2 months of CPAP treatment (both p < 0.01). We also found significant correlations among the improvement rates in BDI, HRSD and ESS scores ( R = 0.86 and 0.75, both p < 0.01). The mixed effect model demonstrated a significant ESS effect on BDI and HRSD. Conclusions The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

Factors associated with functional recovery in bipolar disorder patients

Among bipolar disorder (BPD) patients, functional recovery, defined as regaining individual premorbid residential and vocational status, is far less common than symptomatic recovery. As several factors have tentatively been implicated in outcomes in BPD, we investigated predictors of functional recovery among BPD patients, including demographic, clinical, and neurocognitive factors. We assessed functional recovery status with standardized residential and occupational indices, assessed neurocognitive functioning with performance-based neuropsychological tests, and collected demographic and clinical information for 65 euthymic or residually depressed Structured Clinical Interview for DSM-IV-defined type I or II BPD patients. We examined predictors of functional recovery with multiple logistic regression modeling. More education (p = 0.006), fewer years of illness (p = 0.037), and being married (p = 0.045) were associated independently with functional recovery, even after controlling for residual depressive symptoms, diagnostic type (I versus II), and psychiatric comorbidity. Functionally unrecovered BPD patients performed less well than recovered patients on verbal fluency (effect size = 0.54, p = 0.03), a measure of executive functioning, but this difference was not significant when adjusted for residual mood symptoms and education. Among euthymic or mildly depressed BPD patients, functional recovery was associated with more education, being married, and fewer years of illness.

Are depressive residual symptoms independent of treatments?

Residual symptoms occur in many depressive patients after acute treatment [1]. There is growing evidence that residual symptoms are also prevalent in bipolar disorder during the euthymic phase and in unipolar depression, they are predictors of early relapse [2,3]. In long-term outcome, patients remitting from depression with residual symptoms, have more depressive symptoms and impaired social functioning, thus needing more aggressive treatment [4]. Residual symptoms might be conceived as the persistence of the original mood disorder, despite in a milder presentation, or still be in relation to the neurobiological disorder substrate. Residual symptoms include core mood and functional symptoms of depression. The most common residual symptoms are sleep disturbances, fatigue, and disinterest. The clinician should be aware that patients despite being in apparent remission should be questioned thoroughly in order to identify residual cognitive difficulties, impairment of work and activities, psychic anxiety, sleep disturbances or mild depressive mood [5]. The consequences of low-quality remission impairing psychosocial functioning have to be emphasized. In this presentation we will review the available evidence of the role played by the pharmacological treatments in the residual depressive symptoms.

Correlates of recovery of social functioning in types I and II bipolar disorder patients

Since bipolar disorder (BPD) patients are often functionally impaired, and factors associated with recovery from disability are largely unknown, we investigated demographic, clinical, and neurocognitive correlates of current social functional recovery in 65 stable participants diagnosed with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) type I ( n = 42) or II ( n = 23) BPD. Regaining highest previous levels of social functioning was rated with the Interpersonal Relationships Questionnaire. We also considered neuropsychological test findings as well as demographic and clinical information including mania and depression symptom-ratings. We examined factors associated with social recovery status using univariate analyses and then multiple logistic regression modeling. Of all subjects, 30 (46%) achieved current social functional recovery and 35 (54%) did not. Younger age ( P = 0.005) and lesser current depressive symptoms ( P = 0.02) were associated with social functional recovery, even after controlling for time since the last major mood episode, diagnostic type (II vs. I), co-morbid psychiatric illness, and executive functioning status. The findings are consistent with deleterious effects of even residual depressive symptoms in BPD patients.

Does Night-Time Cortisol Excretion Normalize in the Long-Term Course of Depression?

While there is extensive literature on HPA system activity in acutely depressed patients, there is only limited information about the presence of hypercortisolemia during the interepisode interval of affective disorders. We hypothesized an increase in HPA system activity in depressed patients compared to controls, and proposed that night-time cortisol excretion during follow-up will depend on clinical outcome. We measured night-time cortisol excretion in 27 patients during an acute episode of major depression as well as a 20-week follow-up. 40 healthy subjects served as control group. During the acute episode depressed patients showed increased levels of night-time cortisol excretion compared to healthy controls. Both, patients with full and sustained remission (n=8) as well as patients with incomplete remission or relapse (n=19) showed declining cortisol excretion in night-time urine during follow-up. At the end of follow-up cortisol excretion did not differ between patients with affective disorder and healthy controls. Irrespective of residual depressive symptoms, HPA system activity declines after the generally investigated acute depressive episode.

Relationship Between Residual Symptoms of Depression and Self-reported Cognitive Impairment

The present study aimed to investigate the associations between residual symptoms of depression and specific self-reported symptoms in several cognitive domains. The study investigated 117 patients with partially or fully remitted major depressive disorder (MDD) after treatment with antidepressant medications. Fatigue was significantly associated with inability to focus, alertness, and feeling "blue"; low interest and difficulty with concentration were associated with apathy. No associations were found between deficits in the cognitive domains considered and residual symptoms such as self-blaming, feeling worthless, feeling hopeless, having suicidal thoughts, difficulty with sleep, and lack of appetite. Among MDD remitted patients endorsing residual symptoms such as fatigue and feeling "blue", deficits in a range of cognitive domains should be carefully assessed and treated.

P02-336 - Mindfulness based cognitive therapy for major depression: a systematic review and meta-analysis

ObjectiveMindfulness based Cognitive Therapy (MBCT) is a standardized meditation program which has been proposed as a therapeutic option for the prevention of relapses in patients suffering from major depression (MD). The aim of the present review and meta-analysis is to provide an estimate of the efficacy of MBCT for MD patients.MethodsA literature search was undertaken using MEDLINE, ISI web of knowledge, the Cochrane database, Google scholar and references of retrieved articles. Controlled studies investigating the efficacy of MBCT for MD were entered in the Cochrane Collaboration Review Manager Software (RevMan version 5.0).ResultsReviewed data showed that MBCT in adjunct to usual care was significantly better than usual care alone for reducing MD relpases in patients with 3 or more past episodes of MD. MBCT plus gradual discontinuation of maintenance antidepressants was similar to continuation of antidepressants alone with respect to relapse prevention. The augmentation of MBCT could be useful for patients with current residual symptoms of depression as well.ConclusionsCurrent studies showed preliminary evidence about the efficacy of MBCT for patients with 3 or more past episodes of depression and for currently depressed patients with residual symptoms. However, methodological shortcomings of reviewed studies including small sample size, frequent lack of replications and the absence of studies comparing MBCT to control groups designed to distinguish specific from non specific effects of meditation imply the necessity for further research.

SS01-03 - More complete and sustained remission: the key to success in depression

After the initial response, the next goal is to ensure sustained remission with normal functioning and minimal residual depressive symptoms. During this phase, continued adherence to treatment is needed, which is easier if the patient perceives improvement and tolerates the treatment well. The efficacy of agomelatine, the first melatonergic antidepressant with an innovative mode of action, has been assessed in the long term in 4 studies: (1)the 18-week extension phases of two short-term studies comparing agomelatine (25-50 mg/d) with venlafaxine (75-150 mg/d),(2)a similar extension phase after 6 weeks of treatment versus sertraline 50-100 mg/d, and(3)a specific 10-month placebo-controlled relapse prevention study.At 6 months, more patients responded to treatment with agomelatine either in term of improvement in CGI-I scores as compared to venlafaxine (P&lt; 0.05), or in terms of response rate on the HAM-D as compared to sertraline (P&lt; 0.05). Agomelatine therefore appears to produce in more patients a relief of depressive symptoms than either SNRIs or SSRIs.A meta-analysis showed that a higher percentage of agomelatine-treated patients completed the extension period of 6 months as compared with venlafaxine or sertraline suggesting that clinical improvement induced by agomelatine lead to a better compliance to treatment.The antidepressant efficacy of agomelatine is maintained in the long term, as demonstrated by the prevention of risk of relapse by 56.3% versus placebo over a 10-month treatment period (p&lt; 0.0001).All these features make agomelatine, the option to consider for achieving a full recovery from major depressive disorder.

Toward Depression Remission

Emerging research has found that different neurotransmitters play roles in the regulation of depressive symptomatology and adverse events associated with antidepressant treatment. Residual depressive symptoms and adverse events can lead to noncompliance and the discontinuation of treatment. Several approaches may help clinicians address residual symptoms and tolerability issues in patients with depression.