Cognitive therapy for anxious depression in STAR(*) D: what have we learned?

BACKGROUND: Anxious depression, defined as MDD with high levels of anxiety symptoms, has been associated with lower rates of antidepressant response and remission as well as greater chronicity, suicidality and antidepressant side-effect burden. The primary aim of this study was to assess the effectiveness of cognitive therapy (CT) alone or in combination with medications for anxious versus non-anxious depression. METHODS: We assessed the STAR(⁎)D study participants who were partial or non-responders to citalopram. Subjects were then either switched (n=696) to a new antidepressant or to CT alone, or they were kept on citalopram and augmented (n=577) with another antidepressant or CT. We compared response and remission rates, across treatment conditions, between those who met criteria for anxious depression and those who did not. RESULTS: Those with anxious depression had significantly lower remission rates based on the QIDS, whether assigned to switch or augmentation, compared to those with non-anxious depression. Those with anxious depression, compared to those without, had significantly lower response rates based on the QIDS only in the switch group. There was no significant interaction between anxious depression and treatment assignment. LIMITATIONS: Limitations include the use of citalopram as the only Level 1 pharmacotherapy and medication augmentation option, the relatively small size of the CT arms, use of depression-focused CT rather than anxiety-focused CT, and focus on acute treatment outcomes. CONCLUSIONS: Individuals with anxious depression appear to experience higher risk of poorer outcome following pharmacotherapy and/or CT after an initial course of citalopram and continued efforts to target this challenging form of depression are needed.

Depression and suicidal ideation in college students.

BACKGROUND/AIMS: Suicide is one of the leading causes of death in college students and is often associated with depression. The aim of this study was to assess the rates of suicidal ideation (SI) on college campuses and to identify its correlates. METHODS: On-campus depression screening sessions were conducted at 3 universities (n = 898; 55% female; mean age 20.07 ± 1.85 years). Participants completed the Beck Depression Inventory (BDI; mean ± SD of total score = 6.27 ± 6.31) and other measures. Eighty-four students endorsed a '1' on the BDI suicidality item, suggesting thoughts of suicide. RESULTS: Results showed that students with greater depression severity, higher levels of hopelessness, and poorer quality of life were more likely to endorse SI. CONCLUSION: Factors associated with SI highlighted in this study may aid in the identification of college students at risk for suicide.

Assessing depression and factors possibly associated with depression during the course of Parkinson's disease.

BACKGROUND: Although research suggests depression is common among individuals with Parkinson's disease (PD), it is unclear how to best assess depression in PD (dPD). We wanted to examine the prevalence of dPD using different definitions of depression, as well as examine factors associated with dPD. METHODS: One hundred fifty-eight individuals (68% male; age 66.8 ± 9.6 SD) with a primary diagnosis of PD were assessed for depression using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) in an outpatient setting at the Movement Disorders Clinic at Massachusetts General Hospital. We defined depression using 4 thresholds based on the HANDS and whether or not an individual was ever on an antidepressant regimen. We also examined potential predictors of the presence of dPD. RESULTS: The prevalence of depression among study participants ranged from 11% to 57%, depending on which of the 4 definitions of depression was applied. Younger age and longer duration of PD predicted a relatively higher prevalence of depression. Having a history of depression prior to onset of PD also was predictive of dPD. CONCLUSIONS: Depression appears to be relatively common among individuals with PD, and history of depression, younger age, and longer PD duration may be factors associated with dPD.

Do early changes in the HAM-D-17 anxiety/somatization factor items affect the treatment outcome among depressed outpatients? Comparison of two controlled trials of St John's wort (Hypericum perforatum) versus a SSRI.

To assess whether early changes in Hamilton Depression Rating Scale-17 anxiety/somatization items predict remission in two controlled studies of Hypericum perforatum (St John's wort) versus selective serotonin reuptake inhibitors for major depressive disorder. The Hypericum Depression Trial Study Group (National Institute of Mental Health) randomized 340 patients to Hypericum, sertraline, or placebo for 8 weeks, whereas the Massachusetts General Hospital study randomized 135 patients to Hypericum, fluoxetine, or placebo for 12 weeks. The investigators examined whether remission was associated with early changes in anxiety/somatization symptoms. In the National Institute of Mental Health study, significant associations were observed between remission and early improvement in the anxiety (psychic) item (sertraline arm), somatic (gastrointestinal item; Hypericum arm), and somatic (general) symptoms (placebo arm). None of the three treatment arms of the Massachusetts General Hospital study showed significant associations between anxiety/somatization symptoms and remission. When both study samples were pooled, we found associations for anxiety (psychic; selective serotonin reuptake inhibitors arm), somatic (gastrointestinal), and hypochondriasis (Hypericum arm), and anxiety (psychic) and somatic (general) symptoms (placebo arm). In the entire sample, remission was associated with the improvement in the anxiety (psychic), somatic (gastrointestinal), and somatic (general) items. The number and the type of anxiety/somatization items associated with remission varied depending on the intervention. Early scrutiny of the Hamilton Depression Rating Scale-17 anxiety/somatization items may help to predict remission of major depressive disorder.

Compulsive alcohol use and other high-risk behaviors among college students.

The association between heavy alcohol consumption and risky behaviors has been amply investigated among college students. However, less is known with regard to types of drinking behaviors associated with high-risk activities. The present study extends this area of research by examining the relationship between compulsive drinking and hazardous behaviors in this population. Nine hundred and four college students completed measures on compulsive drinking and other risky behaviors in the context of mental health screenings at three campuses. Results showed that in males, compulsive drinking increased the risk for compulsive street drugs use, compulsive prescription drugs use, compulsive sexual activities, and gambling. Among females, compulsive drinking increased the risk for compulsive street drugs use, and compulsive sexual activities. These findings suggest that inquiring about compulsive drinking among college students may have great utility in identifying those at greater risk for other risky behaviors. The high co-occurrence of compulsive drinking, illicit substances, compulsive sexual activities, and gambling in college students suggests the need for comprehensive programs addressing high-risk behaviors together.

Anxious depression and early changes in the HAMD-17 anxiety-somatization factor items and antidepressant treatment outcome.

The objective of this study was to assess the relationship between early changes in anxiety/somatization symptoms and treatment outcome among major depressive disorder patients during a 12-week trial of fluoxetine. We also examined the relationship between anxious depression and treatment response. Five hundred and ten major depressive disorder patients received 12 weeks of fluoxetine with flexible dosing [target dosages: 10 mg/day (week 1), 20 mg/day (weeks 2-4), 40 mg/day (weeks 4-8), and 60 mg/day (weeks 5-12)]. We assessed the relationship between early changes in 17-item Hamilton Rating Scale for Depression (HAMD-17)-anxiety/somatization factor items and depressive remission, as well as whether anxious depression at baseline predicted remission at study endpoint. Baseline HAMD-17 scores were considered as covariates and the Bonferroni correction (P < or = 0.008) was used for multiple comparisons. Adjusting for baseline HAMD-17 scores, patients who experienced greater early improvement in somatic symptoms (gastrointestinal) were significantly more likely to attain remission (HAMD-17 <8) at endpoint than those without early improvement (P=0.006). Early changes in the remaining items did not predict remission, nor did anxious depression at baseline. In conclusion, among the anxiety/somatization factor items, only early changes in somatic symptoms (gastrointestinal) predicted remission. Future studies are warranted to further investigate this relationship as well as that between anxious depression and treatment outcome.

Effect of affect on social cost bias in social anxiety disorder.

The cognitive model of social anxiety disorder (SAD) assumes that cognitive biases are important maintaining factors of the disorder. Research and theory have highlighted the impact of cognitive self-regulatory processes on affect, but have not sufficiently focused on the influence of affect on self-regulatory cognitions. The present study examined the influence of affect on cognitive self-regulatory mechanisms in SAD by focusing on one critical cognitive bias, estimated social cost. Individuals with SAD (N=48) and non-anxious controls (N=48) were randomly assigned to one of three experimental, affect induction conditions (negative, positive, or neutral) before giving a 10-minute impromptu, videotaped speech. As expected, the affect manipulation resulted in changes in estimated social cost. However, this effect was not specific to individuals with SAD. Participants in the positive affect condition in both groups had the highest social cost estimates post-speech challenge. These results suggest that social cost bias is dependent on the affective state in both individuals with SAD and controls.

A pilot study of sensation-focused intensive treatment for panic disorder with moderate to severe agoraphobia: preliminary outcome and benchmarking data.

This report presents results of a treatment for panic disorder with moderate to severe agoraphobia (PDA-MS) called sensation-focused intensive treatment (SFIT). SFIT is an 8-day intensive treatment that combines features of cognitive- behavioral treatment for panic disorder, such as interoceptive exposure and cognitive restructuring with ungraded situational exposure. SFIT focuses on feared physical sensations as well as agoraphobic avoidance. Preliminary data support the utility of SFIT in improving PDA-MS. The goal of this exploratory study was to further investigate the effectiveness of SFIT and evaluate factors related to treatment outcome, including severity of panic symptoms, gender, comorbidity, self-efficacy, and place of residence (local vs. remote). SFIT was found to be effective in decreasing panic symptoms from pre- to posttreatment, with treatment gains maintained at follow-up. The implications of these findings for the treatment of PDA are discussed.

Sensory-processing sensitivity in social anxiety disorder: relationship to harm avoidance and diagnostic subtypes.

Sensory-processing sensitivity is assumed to be a heritable vulnerability factor for shyness. The present study is the first to examine sensory-processing sensitivity among individuals with social anxiety disorder. The results showed that the construct is separate from social anxiety, but it is highly correlated with harm avoidance and agoraphobic avoidance. Individuals with a generalized subtype of social anxiety disorder reported higher levels of sensory-processing sensitivity than individuals with a non-generalized subtype. These preliminary findings suggest that sensory-processing sensitivity is uniquely associated with the generalized subtype of social anxiety disorder. Recommendations for future research are discussed.

Etiology and treatment of social anxiety: a commentary.

Substantial advances in our understanding of the etiology and treatment of performance anxiety have occurred during the past decade. It has become clear that the development of efficient and effective treatments cannot be divorced from knowledge of the specific form of psychopathology being treated and that treatments must be tailored to this psychopathology. After describing a current model of the etiology of performance anxiety and social phobia, this commentary notes the common factors present across the rich and diverse set of articles in this issue describing treatments from different approaches and different theoretical orientations. To the extent that these common factors are important mechanisms of action, it is possible that the future will introduce more unified and more effective, efficient, and theoretically informed treatment for performance anxiety as well as the potential for preventive techniques.

The impact of medical comorbidity on acute treatment in major depressive disorder.

OBJECTIVE: The authors investigated the impact of medical comorbidity on the acute phase of antidepressant treatment in subjects with major depressive disorder. METHOD: A total of 384 outpatients meeting DSM-III-R criteria for major depressive disorder enrolled in 8-week open treatment with fluoxetine, 20 mg/day. The authors used the Cumulative Illness Rating Scale to measure the burden of medical comorbidity and the 17-item Hamilton Rating Scale for Depression to assess changes in depressive symptoms. The outcome measures were response to treatment (>/=50% reduction in score) and clinical remission (score